Surgical device and accessories

ABSTRACT

The present invention relates to a device developed for surgical interventions comprising (i) an inner end ( 1 ) guidable/steerable to the operation field, (ii) an outer end ( 3 ) operated by the user and (iii) a middle part ( 2 ) which connects both ends ( 1, 3 ) together. According to the main concept of the present invention, it further comprises force transmission units extending between the outer ( 3 ) and the inner ( 1 ) ends, and said force transmission units, the outer and the inner ends and the middle part ( 2 ) are designed to transfer the movements of the outer end ( 3 ) to the inner end ( 1 ) in an identical measure, as if the inner end ( 1 ) were the straight continuation of the outer end ( 3 ).

The present invention is a surgical device system developed for the newtypes of surgical procedures, which is—advantageously similarly to thelaparoscopic technique—able to accomplish all steps (access, surgicalintervention, closure) of NOTES (Natural Orifice Transluminal EndoscopicSurgery), SPLS (Single Port Laparoscopic Surgery) and IE (InterventionalEndoscopy) procedures, and said device system—according to anadvantageous embodiment—comprises laparo-endoscopic instruments, trocarsleeves, a tube or an endoscopic device, and further attachableaccessories.

Within the last few years the marriage of the so-called minimal invasivesurgery (i.e. laparoscopic surgery, characteristically using straightthin and rigid instruments) and endoscopy (i.e. interventions inside thehollow organs through the natural orifices characteristically withflexible instruments) resulted in the birth of the NOTES (NaturalOrifice Translumenal Endoscopic Surgery) technique, which has beenrecently applied mainly in experimental surgery. The desired advantageof the NOTES comparing to laparoscopic surgery (surgery through smallabdominal incisions) includes the further minimization of surgicalintervention and operative risk in the treatment of certain diseases.However, to perform NOTES intraabdominal interventions (e.g. removal ofthe gall bladder, appendix, ligation of the ovarian tubes, etc.) it isnecessary (i) to insert a flexible endoscopic system e.g. through themouth, vagina or the rectum into the abdominal cavity via the holloworgan's wall, (ii) to perform the surgical intervention with the devicein the abdominal cavity, (iii) to remove the necessary tissues or organsout of the body, (iv) to safely close the artificially created openingon the hollow organ's wall at the end of the procedure, and (v) toremove the device-system through the natural orifice.

According to current research there is no device or device-systemavailable, which would be able to perform alone all steps of theaforementioned interventions (i.e. the whole NOTES or SPLS). It must benoted that the currently available devices, which can perform only asingle part of the whole procedure, are still not enough reliable, andin most of the cases their usages are difficult and awkward. It is stilla challenging problem to have these instruments fixed inside theabdominal cavity, to have them arranged in a triangular pattern (theso-called triangulation) to achieve their better coordination andcooperation, and to safely close the artificially created opening on thehollow organ's wall, respectively. The above mentioned difficulties maylead to severe, occasionally to life threatening complications, e.g.injury of vital organs, bleeding or peritonitis.

There are plenty of various devices developed for the NOTESinterventions. Their properties usually evolve as a result of thevarious combinations of laparoscopic and endoscopic features.

One of the most promising recent solutions is described in theUS/2007/086079 patent application. According to this description, theflexible instruments are inserted into the abdominal cavity through theworking channels of an endoscopic tube like device. The inner end ofthis endoscopic device is controlled by its outer end, utilizingtraditional technical solutions. The inner ends of the instrumentsinserted into the endoscopic tube-like device are also controllable by abulky device, which is attached to the outer end of the endoscopictube-like device. However, the disadvantage of this solution is that thefixation of the inner ends of the instruments and the endoscopictube-like device, and the proper triangulation of the instruments remainunsolved. Another drawback is that the device controlling the inner endsof the instruments is relatively bulky, and in case of a new instrumentinsertion it requires additional assembling, and furthermore because ofits relatively large size it needs extended room when more than twoinstruments are inserted. Additionally, this solution does not followthe well prepared and reliable laparoscopic maneuvers but requires newkind of maneuvers. Its main problem is not concerned with the necessityto learn a new technique but with the fact that when any complicationoccurs during a procedure, it is advantageous to solve it with thelaparoscopic technique. The two different techniques may disturb eachother when they are used simultaneously.

Another innovative idea is described in the W0/2008/131046 patentapplication. This instrument is a simple modification of the traditionallaparoscopic instruments: both the head and the handle of the instrumentare bendable simultaneously toward each other. The bending of the handlecontrols the synchronous bending of the head by wires. In fact, thisinstrument was developed primarily for the SPLS (Single PortLaparoscopic Surgery), where usually the navel is used to enter theabdominal cavity. This new SPLS method is considered to be analternative to the NOTES technique. Actually the SPLS is a variation oflaparoscopy. A major drawback of this solution is that the movements ofthe inner and outer ends of the cited instrument are contrariwise ascompared to the conventional laparoscopic instrument, and this is reallydifficult to learn. The relative congestion of the instruments in theabove mentioned ideas is another disadvantage, which could jeopardizethe effectiveness and safety of these procedures.

It is clear from the above that there is a need for the development ofsuch a laparo-endoscopic system, with which all steps of the NOTES, SPLSor IE procedures can be reliably completed through the natural orifices,similarly to the well proved and developed laparoscopic technique.

The object of the present invention is to develop a device-system toreduce the possible complications due to the immature solutions orunsolved problems of NOTES, SPLS or IE, which allows easier, faster andsafer completion of all steps of the NOTES, SPLS or IE proceduresthrough the natural orifices similarly to the reliable and welldeveloped laparoscopic technique.

The present invention is based on the recognition that (i) the complexinner and outer ends of the device-system—acting as the continuation ofeach other—are considered as a unit having laparoscopic features, whilethe middle part—connecting the inner and outer ends together—is ratherregarded as a unit with flexible endoscopic features, and that (ii) themovements of the inner and outer ends of the device—introduced with thehelp of a flexible endoscope-like device through the naturalorifices—are synchronized to move at the same time and degree as theyboth were the inner and outer parts of a traditional laparoscopicinstrument, and that (iii) an appropriately modified endoscopic stapleris used with the help of accessory devices attached to thedevice-system, will make it possible to perform all steps of NOTES, SPLSor IE procedures easier, faster and safer.

Based upon the above recognition, the aforementioned problem will besolved by the application of devices designed for surgicalinterventions, which comprise inner ends guidable to the operationfield, outer ends operated by the user and middle parts connecting theinner and the outer ends together. The main idea of the invention isthat it contains force transmission units extended between the inner andouter ends, and the force transmission units, the inner and outer endsand the middle part are constructed in such a manner, that any movementsof the actuated outer end are transferred in an equivalent degree to theinner end, as if the inner end were the straight continuation of theouter end.

Advantageously there is a channel inside the device, and the forcetransmission unit comprises a first force transmission unit that allowsbending of the outer and the inner ends simultaneously in the samerotational angle and in the same rotational direction relative to themiddle part, and a second transmission unit that transfers thelongitudinal/axial movements of the outer and the inner ends to eachother simultaneously with the same degree but in the opposite direction,respectively.

The outer and the inner ends and the middle part of the device areadvantageously the components of an instrument or a trocar sleeve.Advantageously the outer and the inner ends are connected to the middlepart by articulations. Advantageously both the outer and the inner endsare telescopic. The first and the second force transmission units couldbe integrated in one device, i.e. either in the surgical instrument orin the trocar sleeve, however according to another possible embodimentone of the two force transmission units is incorporated in the surgicalinstrument and the other force transmission unit in the trocar sleevethat contains the surgical instrument inside.

Furthermore the object of the present invention is a tube or anendoscopic device capable to receive one or more surgical instrumentsand/or trocar sleeves, and the tube or the endoscopic device is designedto be able to deliver the inner ends of the instruments and/or thetrocar sleeves to the operation field, and also the inner end of thetube or the endoscopic device is shaped to enable the proper fixationand triangulation of the surgical instruments and/or trocar sleeves.

Furthermore the object of the present invention is a wound closuredevice-system, that according to its main concept contains an implantingtube attachable to other devices and an implanting sheath, there arelocking elements and an implanting rod—that implanting rod is operablethrough its outer end and serves to release these locking elements outof the sheath—inside the implanting sheath, and there are threadsconnecting to each locking elements, and the threads are deliveredthrough the longitudinal split of the sheath and the outer end of thetube, and advantageously the implanting tube, the sheath and theimplanting rod are flexible.

Furthermore another object of the present invention is an endoscopicstapler, which has a body portion and a head portion that are connectedtogether advantageously with articulation, and also has opposed staplingsurfaces on the head portion with a control thread—that allows tensionor relaxation—extending between their free ends, and said thread isadvantageously placed within a longitudinal channel formed inside thehead and the body portions of the stapler.

Furthermore another object of the present invention is a protectivesheath attachable to the outer surface of one or more surgicalinstruments or one or more trocar sleeves or to the outer surface of atube or an endoscopic device that contains one or more surgicalinstruments or trocar sleeves.

Furthermore another object of the present invention is an endoscopicballoon tube, which has two inflatable balloon rings located in anappropriate distance from each other, and has also at least one gas tubethat allows to inflate the balloons, and said endoscopic balloon tubecould be arranged on the inner region of one or more surgicalinstruments or one or more trocar sleeves or on the inner region of atube or an endoscopic device that contains one or more surgicalinstruments or trocar sleeves.

Furthermore another object of the present invention is a catheter thatcan be inserted into the working channel of a trocar sleeve, tube orendoscopic device, and said catheter has an electric unit—which is ableto cut or coagulate tissues—mounted on the inner end advantageously onthe tip of the catheter, said electric unit has an electrical wiringextending along the catheter, and said electrical wiring is connectableto an electric power supply.

According to an advantageous embodiment hereof, the surgical instrumentis inserted into the trocar sleeve, and the trocar sleeves are insertedinto the partially or totally flexible tube or endoscopic device.Advantageously the connections between the tube or the endoscopic deviceand the trocar sleeves and the surgical instruments allow both axial androtational movements to each other. If required, further accessorydevices (e.g. protector sheath, wound closure device, endoscopicstapler, etc.) could be attached to their inner or outer surfaces.Advantageously all connections allow longitudinal movement or slidingalong the longitudinal axis and rotation around the longitudinal axis,respectively.

According to an advantageous embodiment of the surgical instruments, thesurgical instrument advantageously consists of three parts: thepartially flexible middle part and the two telescopically extendablerigid inner and outer ends, and said inner and outer ends are connectedto the middle part through joint-like articulations. Advantageously thesegments of the middle part adjacent to the articulations are alsorigid. The cross section of the instrument is advantageously circular.

Advantageously the outer and the inner ends of the instrument aresimultaneously bendable at the articulations relative to the middle partin the same rotational angle and in the same rotational direction (whenthe middle part is in straight position, the rotational axes of theouter and inner ends at the articulations are parallel with each other),as if the outer and the inner ends were the components of onetraditional laparoscopic instrument. The bending of the inner and theouter ends are executed advantageously only in one common plane (in casethe middle part is in straight position) and advantageously through apair of antagonistic wires, and said wires extend from the inner endthroughout the articulations and the middle part to the outer endopposite to each other. Of course, other embodiments make it possiblethat the articulations are bendable in more than one common planeutilizing more than one pair of antagonistic wires. It is obvious thatany recent technical solution is also acceptable to achieve the abovedescribed bending mechanism. Such possible solution could be a flexibleor rigid pusher rod that is placed within the middle part and isconnected to both the outer and the inner ends.

Of course any recent solutions concerning the construction of thearticulations can offer the benefits referred above. The articulationsthat connect together the outer and the inner ends with the middle partmay have more than one component.

There is a releasable ratchet locker located at the articulation thatconnects the middle part and the outer part together. The ratchetmechanism with the locker can fix the desired angle between the middlepart and the outer and the inner ends transiently or permanently. Thelocker function is activated or deactivated upon request.

The telescopic ends consist of rigid straight tubes, which areinsertable into one another. The head of the surgical instrument islocated on the inner telescopic end, and advantageously is constructedsimilarly as the head of any recently used laparoscopic instruments,including the camera as well. The handle is situated on the outertelescopic end of the surgical instrument, and advantageously it is alsoconstructed similarly as the handle of any recently used laparoscopicinstruments, including the camera as well. The opening and the closingmovements of the handle of the instrument control the function of thehead with the help of a motive wire that extends from the outer endthrough the middle part to the inner end. The functions of theinstrument, according to the present invention, also offer the samefunctions as any current instruments designed for any kind of energytransmission (e.g. electric, ultrasonic, etc.) on the field of surgery.

In spite of the fact that the outer and the inner telescopic ends areseparated form each other by the middle part, they move togethersimultaneously, as if they were the straight continuation of each other,similarly to the movements of the inner and outer ends of a straighttraditional laparoscopic instrument. When, for example, the outertelescopic end is pushed to some extent, that is, its length is reduced,the length of the inner telescopic end becomes simultaneously elongatedwith the same extent, and this works vice versa of course. This movementis directed by the force transmission unit situated inside the surgicalinstrument.

According to an advantageous embodiment this force transmission unit islocated inside the channel of the instrument and advantageously consistsof ball shaped force transmission particles. The channel extends fromthe inner telescopic end through the middle part to the outer telescopicend. The full length of the channel is filled up with balls. Thediameter of the ball is somewhat smaller than the inner diameter of thechannel. Advantageously there are holes in the middle of the balls, andthe motive wire travels through these holes from the handle to the head.Advantageously the channel is provided with antifriction material.Advantageously the ball like force transmission particles are able topass easily through the channels at the articulations. When the handleof the instrument is pushed forward, the handle push the last ball inthe channel of the outer telescopic end. The adjacent balls transferthis pushing force to one another, and at last the first ball in thechannel of the inner end pushes forward the head of the instrument,resulting in the elongation of the inner telescopic end. To execute themovement in the opposite direction that is to reduce the length of theinner telescopic end, it is advantageous to utilize a wire that connectsthe two telescopic ends together, and for this purpose the motive wireis also acceptable. When pulling the handle of the instrument, the outertelescopic end becomes elongated and the wire—fixed to thehandle—simultaneously pull in the inner telescopic end. If the freetransmission is guaranteed, any other form distinct from the ball shapeis suitable. The bendable connections among the force transmissionparticles, which are threaded by the motive wire, are designed to resisttheir compression along the longitudinal axis and to resist theirtorsion to each other around the longitudinal axis.

According to another advantageous embodiment the force transmission unitis a hydraulic unit advantageously with elastic capsule, and saidhydraulic unit is located inside the channel described above. Accordingto an advantageous embodiment, the hydraulic unit has three parts: theinner and the outer ends and the middle part. The three parts of thehydraulic unit communicate with one another and they form together onecommon cavity. This hydraulic unit is a closed system and the hydraulicfluid does not communicate with the outer environment, it only flowsthrough the three parts of the common cavity. The middle part of thehydraulic unit is located advantageously in the channel of the middlepart of the instrument, and their lengths are equal, and said middlepart of the hydraulic unit is fixed to the channel in order to avoidshifting. The inner and the outer ends of the hydraulic unit are locatedinside the channels of the inner and the outer telescopic ends of theinstrument. The inner and the outer ends of the hydraulic unit areadvantageously designed to allow only longitudinal expansion orreduction along their longitudinal axis without any change in theirdiameter. The capsules of the ends of the hydraulic unit areadvantageously able to move within the channels of the ends of theinstrument along its longitudinal axis. One possible advantageoussolution regarding the ends of the hydraulic unit would be the accordionlike folding of the walls of both ends. When the outer telescopic end iscompressed longitudinally because the handle of the instrument ispushed, the accordion shaped outer end of the hydraulic unit becomessimultaneously compressed along its longitudinal axis. Thereby theelevated pressure within the outer end of the hydraulic unit istransferred through the fixed hydraulic middle part to the innerhydraulic end resulting in the longitudinal expansion of the accordionfolded inner hydraulic end that leads to the elongation of thetelescopic inner end as well. Advantageously the extent of theelongation and the extent of the shortening are equal. Along with theaccordion folded design, a similar result can be achieved, if the wallof the hydraulic unit is made of appropriately elastic material. Toexecute the movement in the opposite direction in order to reduce thelength of the inner telescopic end, it is advantageous to utilize a wirethat connects the two telescopic ends together, and for this purpose themotive wire is also acceptable. When pulling the handle of theinstrument, the outer telescopic end becomes elongated and thewire—fixed to the handle—simultaneously pulls in the inner telescopicend.

Yet another possible design of the force transmission unit is a flexiblesheath placed within the channel of the instrument, which, according toan advantageous solution, is a coiled spring or a plastic tube. Themotive wire is inside the flexible sheath. Advantageously the flexiblesheath has insulating properties. Advantageously the flexible sheathresists compression along the longitudinal axis and also resists torsionaround the longitudinal axis.

The head situated on the inner end of the instrument can be rotatedaround the longitudinal axis. The rotation of the head is controlled bythe rotation of the outer end of the instrument, advantageously withoutthe need to rotate the handle. The rotation of the handle advantageouslyis independent from the rotation of the head. Advantageously the headlocated on the inner end and the outer end rotates with the same degree.The rotation of the head and the inner end by the outer end is executedvia the connected force transmission particles—said connections amongthe particles resist to the torsion effects around the longitudinal axisas described before, or is executed via the flexible sheath that alsoresists to the torsion effects around the longitudinal axis. Of courseany other known solutions are acceptable with regard to the rotation ofthe head.

On the middle part of the instrument at least one connecting ring isplaced advantageously to connect between the tube and the instrument.The instrument is easily rotatable within the ring. There is aconnecting groove formed on the outer surface of the ring. According toanother advantageous solution, a thread with needle is connected to thering which helps to fix of the middle part of the instrument to any partof the abdominal wall.

According to another advantageous embodiment the instrument isattachable to the tube through a simple trocar sleeve. There is asliding connection between the tube and the trocar sleeve, and themiddle part of the instrument is located in the trocar sleeve. Themiddle part of the instrument is advantageously longer than the trocarsleeve. The instrument is rotatable and forth and back slideable withinthe trocar sleeve. Advantageously there is a valve and an airtight ringon the outer end of the trocar sleeve.

According to another advantageous embodiment the instrument has threemain components: the partially flexible middle part and the rigidtelescopically extendable outer and inner ends which are connected tothe middle part through joint-like articulations. The force transmissionsystem is the same as described above. The instrument has no wire toexecute the bending of the telescopic ends. According to this solutionthe instrument is connected to the tube with such a trocar sleeve whichhas a partially or totally flexible middle part, and rigid outer andinner ends that are connected to the middle part through articulations.The bending of the outer and the inner ends are executed by theantagonistic wires located within the trocar sleeve. Advantageously theratchet mechanism is mounted on the outer articulation. There isadvantageously a valve and an airtight ring located on the outer end ofthe trocar sleeve.

The length of the middle part of the trocar sleeve is advantageouslylonger than the length of the tube. There is a sliding connectionbetween the trocar sleeve and the tube. The length of the middle part ofthe instrument is advantageously longer than the length of the middlepart of the trocar sleeve. The instrument within the trocar sleeve iseasily moveable along the longitudinal axis and also rotatable aroundthe longitudinal axis.

According to another advantageous embodiment the instrument consists ofthree main parts: the flexible middle part and the non-telescopic rigidouter and inner ends. The motive wire is situated inside the instrument.There is no additional force transmission unit within the instrument, asthis transmission function is executed by the middle part and the tworigid ends.

An instrument constructed this way is connected to the tubeadvantageously through a trocar sleeve which has a partially or totallyflexible middle part and with articulations connected rigid telescopicouter and inner ends. The simultaneous bendings of the articulations asdescribed earlier are executed by the antagonistic wires situated withinthe wall of the trocar sleeve. Similarly, the ratchet mechanism could beformed on the outer articulation. The simultaneous elongation andshortening of the telescopic ends of the trocar sleeve are the resultsof the forward or backward movements of the instrument within the trocarsleeve. Advantageously there is a sliding connection between the trocarsleeve and the tube, which allows free movements along the longitudinalaxis. Advantageously the sliding connection is accomplished by at leastone connecting ring situated on the middle part of the trocar sleeve,and said ring is freely rotatable around the middle part. Advantageouslythe ring has a connecting groove that is connected with the rail mountedon the inner surface of the tube. There is an airtight valve and a ringon the outer end of the trocar sleeve.

According to an advantageous embodiment the trocar sleeves are connectedto one another through sliding connections mounted longitudinally ontheir outer surfaces, and each trocar sleeve is connected with the twoadjacent trocar sleeves to form a cylindrical arrangement.Advantageously four connected trocar sleeves are sufficient to performmost surgical interventions. In this case the cross section of eachconnected trocar sleeve is advantageously a quarter sector, and theytogether make a full circle, thereby the common outer cylindrical formmakes a gentler intervention possible (e.g. when penetrating through thegastric wall). The sliding connections (a groove or a rail fitting toone another) are situated on the flat superficia of the trocar sleeves,and said sliding connections allow the longitudinal movements of thetrocar sleeves relative to each other. This kind of trocar sleeve hastwo flat superficia, one of them has the groove and the other has therail that fits to the groove. The cross sections of the working channelsof the trocar sleeves are advantageously rounded. This kind of trocarsleeves could be partially or totally flexible or rigid. The inner endof the trocar sleeves may have an oblique plane allowing easierpenetration through the stomach wall.

According to this possible solution, to the trocar sleeves with sectorcross sections, rigid outer and inner telescopic ends are advantageouslyattached through articulations. Advantageously the cross sections of thetelescopic ends are round, and said ends are rotatable relative to themiddle part around the longitudinal axis. In this case there is no forcetransmission unit to actuate the telescopic ends. This telescopicfunction is executed by the surgical instrument located within theworking channel of the telescopic trocar sleeve, and said instrument hasa flexible middle part and rigid outer and inner ends, and is able tomove longitudinally forth and back in the working channel. Thesimultaneous bending of the telescopic ends at their articulations areadvantageously directed by a pair of antagonistic wires located withinthe trocar sleeve. At the outer end of the trocar sleeve there is anairtight valve and a sealing ring.

There are several other possible solutions to connect the trocar sleevestogether. According to an advantageous embodiment, the additional trocarsleeves are connected to the outer surface of a double trocar sleevethrough sliding connections. Advantageously the trocar sleeves areattached to the junction part of the double trocar sleeve. In additionfurther connecting grooves or rails could be formed on the outersurfaces of the double trocar sleeve or on the additionally attachedtrocar sleeves to connect them e.g. with a thread, stick or rod toensure their fixation to the abdominal wall.

According to another advantageous embodiment, the trocar sleeves areconnected to the outer surface of a trocar guide through slidingconnections. The connecting grooves or rails are mounted on the outersurface of the trocar guide. Inside the trocar guide a smaller diameterworking channel could be situated, which could be used to insert e.g. aballooned access catheter. The inner end of the trocar guide isadvantageously sharp. According to a further advantageous embodiment theadditional trocar sleeves are attached to a central trocar sleevethrough sliding connections. Advantageously the outer cross section ofthe central trocar sleeve is optional, while the cross section of theworking channel inside the central trocar sleeve is round.Advantageously there could be further channels located inside thecentral trocar sleeve, e.g. gas or suction-irrigation channels. Theconnecting grooves or the rails are mounted on the outer surface of thecentral trocar sleeve.

A tube is not necessary to introduce the trocar sleeves if they areconnected together. The trocar sleeves could be fixed to the abdominalwall transiently or permanently with a ring located advantageously nearto the inner end of the middle part. The fixation is possible with athread with a needle, or with a rigid stick or with a control rod. Theconnected trocar sleeves within the ring are free to move along and torotate around the longitudinal axis, respectively. In case no tube isused, advantageously there could be connecting grooves or rails formedon the outer surfaces of the trocar sleeves to allow the connection ofother endoscopic devices.

The trocar sleeves connected together by sliding connections are alsoinsertable into the abdominal cavity or fixable to the abdominal wallwith the help of a partially or totally flexible simple tube. In thiscase there is no groove or rail formed inside the tube, they are formedonly on the outer surface of the tube. The inner end of the tube mayhave a normal (i.e. flat), oblique or step-form shape. There may be athread, stick or rod connected to the outer surface of the inner end ofthe tube, each of them allows fixing the tube to the abdominal wall. Thestick may have a connecting foot that fits into the advantageouslylongitudinally situated connecting groove on the outer surface of thetube, and said connecting foot is slideable within the groove. In thiscase the inner end of the tube, which is fixed to the abdominal wallwith the stick, is slideable back and forth by the help of theconnecting foot, thereby allowing the proper adjustment of the inner endover the designated operating field. At the same time by the help of therigid stick or rod the inner end of the tube is easily maneuverable toany desired part of the intraabdominal cavity, or is fixable in anydesired location and position, respectively. Of course several otherouter endoscopic devices (e.g. wound closure device, camera, forceps,etc.) could be connected to the groove located on the outer surface ofthe tube.

In the following part hereof, the tubes and the endoscopic devicescontaining surgical instruments and/or trocar sleeves will be discussedwith their possible advantageous embodiments.

The tube refers to a solution, which has a long cylindrical bodyadvantageously with one single lumen inside, and into this lumensurgical instruments, trocar sleeves or other accessory devices could beinserted.

According to the simplest advantageous solution both ends of the tubeare normal (i.e. straight). Advantageously the outer and the inner endsof the tube could be rigid and the middle part could be flexible. Theinner diameter of the tube makes it possible to insert more thanone—advantageously four—trocar sleeves. The inner surface of the tubecould be completely smooth, or according to an advantageous embodiment,may have longitudinal connecting grooves or rails on the inner surface.Advantageously there could be longitudinal connecting grooves or railsalso on the outer surface of the tube. A thread, a stick or a rod couldbe attached to the outer surface of the tube advantageously at the innerend region. There is advantageously a joint-like articulation betweenthe inner end and the middle part of the tube. The inner end is bendableat the articulation relative to the middle part by the help of a pair ofwires that extend longitudinally throughout the tube, and anarticulating device mounted on the outer end of the tube. The opening ofthe inner end of the tube could be normal (i.e. straight), oblique orstep-form. The inner opening is straight if the plane of the inneropening is perpendicular to the longitudinal axis of the tube. The inneropening is oblique if the plane of the inner opening is notperpendicular to the longitudinal axis of the tube. The inner opening isstep-form, if the straight or oblique opening is combined together withan opening located on the side of the inner end of the tube (the planeof the side opening is advantageously parallel with the longitudinalaxis). The step-form opening has a greater advantage because itsignificantly expands the size of the interventional area and assuresthe easier maneuvers. The greater the size of the opening of the innerend facing toward the operation field, the greater is the freedom ofmovements of the instruments. This opening area could be readilyenlarged to the desired size by additionally increasing the size of theside opening component.

The enlarged diameter of the inner opening makes it possible toarbitrary increase the distance between the inner articulations of theinstruments by pushing the instruments relative to one another alongtheir longitudinal axis. The possible extent of the instrumentsdislocation is determined advantageously by the largest diameter of theinner opening. According to an advantageous solution, the direction ofthe largest diameter of the inner opening tends toward the direction ofthe longitudinal axis of the device. During laparoscopic surgery theintervention could be performed optimally only in case the operationfield and the two operating instruments form a triangle with anappropriate wide base (this is the so called triangulation), and saidbase of the triangle is determined by the distance between the twoinstruments inserted into the abdominal cavity. In case of laparoscopicsurgery the size of the triangle base—i.e. the distance between the twooperating instruments—is alterable only if one of the instruments isremoved and then reinserted through another location—i.e. new wound—intothe abdominal cavity across the abdominal wall.

According to the present invention the size of the triangulation basecould be altered (increased or decreased) without the need to createadditional wounds across the abdominal wall. In case of oblique orstep-form openings the size of the triangle base is determined by thelargest diameter of the inner opening. The distance between the innerarticulations of the instruments (i.e. the size of the triangle base) isoptionally alterable (enlarge or reduce) by the relative shifts of theinstruments along their longitudinal axis, depending on the largestdiameter of the inner opening. In case of a tube or endoscopic devicewith a normal (straight) end the size of the triangle base isunfortunately small, contrarily the oblique or the step-form openedinner end provides with a significantly larger size. In addition thestep-form opening is more advantageous than the oblique opening becauseit ensures the reliable connections—said connections allow movementsalong the longitudinal axis and rotation around the longitudinal axis—ofat least two instruments or trocar sleeves to the tube or to theendoscopic device within the entire extent of the inner opening. Thereliable connection between the instrument or the trocar sleeve and theinner end of the tube or the endoscopic device guarantees theappropriate stability to the inner end of the instrument or the trocarsleeve in order to perform the surgical intervention with safemaneuvers. It is a remarkable advantage of the present invention that itallows the optional and stable alteration of the size of the trianglebase without creating additional wounds, and furthermore allows theoptional change in the position of the inner end of the tube or theendoscopic device (e.g. with a control rod) and the fixation of theinner end in the new position to ensure the optimal access to anyoperation field. For all these results the adjustable telescopic endsare also necessary, of course.

The ability to arbitrary change the size and/or the position of thetriangulation base without the need to create additional wounds isconsidered to be a significant advantage over the recently used modernlaparoscopic technique.

An independent opening could be situated also on the wall of the middlepart of the tube. Advantageously there is an articulating device, a gasconnection, and an arbitrary detachable or attachable airproof cap,closing the outer opening, mounted on the outer end of the tube. The capis attached to the outer end by means of screw-threads or by any otherknown airproof connections. There are cap openings with valves on thecap.

In case of the SPLS procedures advantageously the whole tube is rigid.

In case of either solution referred above an optional external fixateurdevice could be attached to the outer end of any instrument, trocarsleeve, tube or endoscopic device, and said external fixateur device isable to fix the outer end transiently or permanently in a desiredposition.

In case of either solution above the inner end of any instrument, trocarsleeve, tube or endoscopic device could be fixed via a thread, or astick or a control rod, being attached to the inner end, to theabdominal wall and/or to an external fixateur device.

The endoscopic device refers to a solution, which has a long cylindricalbody advantageously with more than one working channels inside.Advantageously there could be connecting grooves or rails formed on theouter surface of either type of endoscopic device in order to establishadditional external connections (e.g. with a thread, stick, control rod,stomach closure device, etc.). According to an advantageous embodimentthere could be an articulation formed at the inner end of either type ofendoscopic device, and said articulation is bent by a pair of wires andan articulating device. This pair of wires extends through the entireendoscopic device and is connected to the articulating device located atthe outer end of the endoscopic device. The inner and the outer ends ofeither type of endoscopic device are advantageously rigid and the middlepart could be flexible or rigid. Either endoscopic device may haveoptionally a gas channel and a suction-irrigation channel.

According to a possible advantageous solution the endoscopic device isdivided. In this case the endoscopic device is partially or totallydivided into two parts (upper and lower parts) by a plane that isadvantageously parallel with the longitudinal axis. The two parts areconnected together by sliding connection, and they are optionallymovable back and forth along their longitudinal axis relative to eachother. The dividing plane may divide the working channel inside theendoscopic device into two complementary divided working channels. Whenthe two divided parts of the endoscopic device are shiftedlongitudinally relative to each other, the divided working channelsbecome free at their inner ends. The instruments bent at their innerarticulations are easily movable back and forth within the free part ofthe divided working channels with or without the trocar sleeves. Thefree part of the divided working channel is advantageous because itallows the telescopic inner end and head of the instrument—i.e. the partthat is distal to the inner articulation—to exit from the dividedworking channel along the full length of its free part in order to reachthe interventional area. The length of the free parts of the dividedworking channels could be changed optionally (increase or decrease) byshifting the two divided endoscopic parts longitudinally relative to oneanother. According to and advantageous arrangement of the four workingchannels, the plane dividing the endoscopic device into two longitudinalparts also divides longitudinally two opposite working channels. Theother two working channels—advantageously the upper and the lowerchannels—remain intact. The normal or oblique inner ends of the dividedendoscopic device could be transformed into a step-form inner end by thelongitudinal shift of the two parts (advantageously only the upper partor only the inner part) relative to one another.

According to a possible advantageous embodiment the outer end of thedivided endoscopic device is rigid. The rigid end of the upper part ofthe device is completed to a full cylinder, in such a way, that therigid end of the slidable lower part is also inside the cylinder Theouter end completed to a full cylinder is airtight and hasadvantageously four air proof openings with valves, and said openingsare the inlet openings of the intact or divided working channelssituated within the endoscopic device. The airtight closure of thecylindrical common end may be also achieved by an optionally securablecap with airtight inlet openings and valves.

Advantageously the trocar shaft—i.e. the rigid tube-like continuation ofthe lower part—exits the common cylindrical end through the lower outeropening. The trocar shaft—provided with a valve—is the externalcontinuation of the intact working channel located inside the lowerendoscopic part, and said trocar shaft, which extends through the lowerouter opening, has an ear-like handle at the outer end that helps tomove the lower endoscopic part longitudinally back and forth.Advantageously the trocar shaft is shifted in and out through the lowerouter opening of the common cylindrical end by the help of the ear-likehandle, which consequently means the longitudinal back and forthmovement of the inner end of the lower endoscopic part. Thereby the sizeof the step-form inner opening—and consequently the size of theinterventional area—is optionally adjustable.

According to another possible solution, the plane dividing theendoscopic device parallel with the longitudinal axis does not divideany of the working channels. Advantageously both the upper and the lowerendoscopic parts contain two intact working channels. In this case theshape of the outer end of the endoscopic device could be a commoncylinder similarly to the previous solution, except that now two rigidtrocar shafts, which are the external continuation of the two workingchannels of the lower endoscopic part, exit trough the two lower outeropenings of the common cylindrical end.

According to another possible solution, the outer ends of the dividedendoscopic device are similarly divided as the inner ends, and bothouter ends are hermetically sealed. The upper and lower outer ends haveairtight outer openings with valves. In this case either endoscopicpart—the upper and the lower endoscopic parts are connected together bysliding connection—could be removed from the patient and could bereplaced with a larger instrument (e.g. an endoscopic stapler), orthrough the space of the removed endoscopic part also tissue or organspecimens could be removed.

According to another advantageous embodiment the endoscopic device issolid and undivided. The opening of the inner end of the device could benormal, or oblique or step-form. In case the inner end has a step-formopening there could be one or more working channels divided partiallyadvantageously only at the inner end region, in order to achieve theabove detailed advantages. Advantageously the upper and the lowerworking channels are intact (i.e. undivided) while the other workingchannels on both sides are divided at their inner ends. Of course a pairof intact (i.e. undivided) upper and a pair of intact lower workingchannels arrangement is also possible. The outer end of the undividedendoscopic device is hermetically sealed and there are airtight outeropenings with valves, and said outer openings are the inlets of theworking channels.

Inside the divided working channels of any type of endoscopic devicethere are sliding connections (e.g. sliding rim, connecting groove orrail) allowing the proper attachment and fixation, and the longitudinalback and forth movement of the inserted trocar sleeve or instrument.This connecting components (e.g. sliding rim, connecting groove or rail)are connected to the connecting components of the instruments or thetrocar sleeves.

The outer end of any type of tube or endoscopic device may have a coneshape. This is advantageous because it allows the easier handling of theouter ends of the instruments.

Any type of the previously mentioned instruments, trocar sleeves, tubesor endoscopic devices could be combined to perform the NOTES/SPLSprocedures appropriately.

Advantageously any type of tube or endoscopic device may have aprotective sheath. The protective sheath is advantageously cone shapedand is made of a strong clingfilm-like material, that on the outer endhas a connecting ring or tube—able to connect airtight to the outer endof a tube or an endoscopic device—, and on the inner end it has anexpandable ring. The protective sheath covers the tube or the endoscopicdevice. The protective sheath is inserted via a natural orifice into theabdominal cavity through the wound on the wall of a hollow organadvantageously in a rolled position over the tube or the endoscopicdevice. When the protective sheath enters the abdominal cavity, theexpanding cone shaped inner end with the expandable ring and thecontracting wound around the protective sheath prevent to escape the gasfrom the insufflated abdominal cavity. In addition the protective sheathprotects the wall of the hollow organs and the adjacent area against theinjuries caused by the moving instruments, and prevents the contact withthe contaminated secretions, or with the diseased tissues or organs. Thecone shaped inner end (i.e. the inner end has a larger circumference)allows to remove the tissues or organs easier. Of course any other shapeof the protective sheath could be among the possible solutions.

According to another solution an independently inflatable endoscopicballoon tube could be placed advantageously on the inner end region ofthe tube or endoscopic device. This device is placed into the wound onthe wall of a hollow organ, in order to prevent gas leakage. When theendoscopic balloon tube is already inserted the air ducts of theballoons extend over the natural orifice.

In any of the previously described instrument—trocar sleeve—tube orendoscopic device system, or instrument—trocar sleeve system, orinstrument—tube or endoscopic device system the inserted instruments areable to reliably reproduce all three-dimensional laparoscopic maneuversby the help of bandings, rotations and telescopic movements.

Any type of the previously described instruments, trocar sleeves, tubesor endoscopic devices may have a disposable or a reusable design.

Any type of the previously described instruments, trocar sleeves, tubesor endoscopic devices may have a design allowing their disassembling,cleansing and reassembling.

Hereinafter come the descriptions of the accessory devices.

One of such accessory instrument is the access catheter, which enablesto create a wound opening on the wall of a hollow organ (e.g. thestomach) during the access phase. The catheter could be inserted intoany suitable working channels. There is an electric unit—that is able tocut or coagulate tissues—mounted on the inner end advantageously on thetip of the catheter, said electric unit has an electrical wiringextending along the catheter, and said electrical wiring is connectableto an electric power supply. The electric unit is slightly recessedwithin the tip of the catheter in order to avoid the direct contact withextended tissue areas. There are two consecutive balloons on thecatheter. The one closer to the inner end has advantageously anumbrella-like shape characteristically with a diameter—that isperpendicular to the longitudinal axis—larger than that of the tube orthe endoscopic device. The next one is the dilating balloon that hasadvantageously a cylinder-like shape and its diameter is smaller thanthat of the tube or the endoscopic device. The balloons areindependently inflatable or deflatable, and their air ducts extend overthe outer end of the tube or the endoscopic device.

Another such an accessory device is the wound closure device allowingthe closure of a wound created on the wall of a hollow organ. Accordingto an advantageous embodiment the wound closure device consists of animplanting tube, an implanting sheath, locking elements, threads and animplanting rod. The groove or rail on the outer surface of theimplanting tube could be connected with sliding connection to the railor groove on the outer surface of the trocar sleeve, tube or endoscopicdevice. There are locking elements on the inner end of each thread andthere is one fixing knob on their outer ends. The locking elements areinside the implanting sheath, and the sheath with the threads is insidethe implanting tube. The inner end of the implanting sheath is sharp andthere is a longitudinal split on the side of the sheath, and there is animplanting rod located above the locking elements. The locking elements,the implanting rod, the implanting sheath, the threads and theimplanting tube are moveable to each other or to a trocar sleeve, tubeor endoscopic device, respectively. The implanting rod, the implantingsheath and the implanting tube are advantageously flexible.

The third accessory device is advantageously assembled by rigidcomponents, and allows the optional fixation of the outer and the innerends of a trocar sleeve, tube or endoscopic device. One end of thisfixateur device is fixed independently from the patient, e.g. to theoperating table. One type of the external fixateur device could besuitable to fix the thread, or stick or rod connected to the outersurface of the inner ends, while another type of the device is suitableto fix the outer ends. The shape, the angle and the position of thefixateur device is optionally fixable or changeable.

The fourth accessory device could be a modified endoscopic stapler.Advantageously the head of the stapler is rigid and the body ispartially or totally flexible. The head and the body are connectedtogether advantageously by an articulation. The stapling surface of thehead is advantageously perpendicular or parallel to the longitudinalaxis of the device, but any other inclination angle is possible. Thereis a control thread located between the free ends of the staplingsurfaces, and said control thread could be optionally tensioned orrelaxed. The thread is situated within the channel that extendsthroughout the head and the body of the device. The end of the threadextends over the outer end of the stapler. When the control thread istensioned the desired part of the tissue is directed among the staplingsurfaces. Under full tension the thread supports the parallel closure ofthe mobile jaw of the stapler head. Advantageously there may be aworking channel inside, or a groove or rail on the outer surface of thebody of the stapler and said groove or rail allows the connection of anaccessory device (e.g. a trocar sleeve, a camera, a forceps, etc.). Thestapling surfaces may have straight, curved, wavy or any other recentlyknown shape. The diameter of the stapler is preferably smaller than theinner diameter of the tube.

Any further advantageous embodiments are detailed in the subclaims.

In the following part hereof, the invention will be described in detailwith reference to the drawings attached hereto showing the advantageousembodiments of the instrument.

In the drawings

FIG. 1/A shows the possible solution of the joint-like articulation andits bending system according to the present invention,

FIG. 1/B shows the possible solution of the telescopic instrument withthe ball-like force transmission particles according to the presentinvention,

FIG. 1/C shows the possible solution of the telescopic instrument withthe hydraulic force transmission unit according to the presentinvention,

FIG. 1/D shows the possible solution of the advantageously closedhydraulic unit,

FIG. 1/E shows one possible solution for the ratcheting mechanismlocated at the region of the outer articulation,

FIG. 1/F shows the cross section of the instrument with ball-like forcetransmission particles according to the present invention,

FIG. 1/G shows the cross section of the instrument with hydraulic unitaccording to the present invention,

FIG. 1/H shows the connecting ring attachable to the instrumentaccording to the present invention,

FIG. 1/I (on the drawing page 2/29) shows the longitudinal section ofthe instrument with a flexible sheath according to the presentinvention,

FIG. 2/A shows a possible advantageous solution of the trocar sleeveaccording to the present invention,

FIG. 2/B shows an advantageous solution of the telescopic instrumentaccording to the present invention,

FIGS. 2/C and D show the ring with a connecting groove, thread andneedle that is attachable to a telescopic instrument according to thepresent invention,

FIG. 2/E shows the ratcheting mechanism located at the outerarticulation,

FIGS. 3/A and B show one possible advantageous solution of thetelescopic trocar sleeve according to the present invention,

FIG. 3/C shows one possible solution of the instrument with flexiblemiddle part according to the present invention,

FIG. 3/D shows the ring attachable to the telescopic trocar sleeveaccording to the present invention,

FIG. 3/E shows the ratcheting mechanism mounted on the outerarticulation,

FIG. 4/A shows an advantageous solution of the tube with straight innerend according to the present invention,

FIG. 4/B shows an advantageous solution of trocar sleeves withsector-like cross sections that are connected together through slidingconnections according to the present invention,

FIGS. 4/C, D and E show an advantageous solution of the inner ends ofthe telescopic trocar sleeves—with sector-like cross sections—that areconnected together through sliding connections according to the presentinvention,

FIG. 4/F shows according to the present invention the cross section ofthe trocar sleeves (having sector-like cross sections) within the tube,

FIG. 4/G shows according to the present invention the cross section ofthe trocar sleeves (having sector-like cross sections) that areconnected together through sliding connections,

FIG. 5 shows the possible dimensions of the movements of the instrumentand its similarity to the laparoscopic movements according to thepresent invention by illustrating the inner virtual end (dashed line) asthe straight continuation of the outer end on the drawing,

FIGS. 6/A, B, C, D, E and F show one by one the possible dimensions ofmovements of the instrument according to the present invention,

FIG. 7 shows a possible position of the laparo-endoscopic systeminserted into a patient according to the present invention,

FIG. 8 shows according to the present invention one possible position ofthe laparo-endoscopic system to perform the removal of the gall bladder,

FIG. 9/A shows according to the present invention one advantageoussolution of the tube with a step-form opened inner end,

FIG. 9/B shows according to the present invention the oblique openedinner end of the tube,

FIG. 9/C shows according to the present invention one possible solutionof the tube with either an oblique or a step-form opened inner end,

FIG. 9/D shows according to the present invention a possible solution ofthe endoscopic balloon tube that could be pulled over the tube,

FIG. 9/E shows according to the present invention a possible solution ofthe cup that is able to hermetically seal the outer end of the tube,

FIG. 9/F shows according to the present invention two possible crosssections of the tube,

FIG. 10 shows according to the present invention an advantageoussolution of the step-form opened inner end of the tube,

FIG. 11 shows according to the present invention the suggested positionof the laparo-endoscopic system with step-form opened inner end duringgall bladder surgery, and the advantageous use of the control rod,respectively,

FIG. 12/A shows according to the present invention an advantageoussolution of the divided endoscopic device with normal (straight) innerends and the protective sheath,

FIG. 12/B shows the longitudinal sliding of the parts of the previousendoscopic device and the trocar shaft and the protective sheath,

FIGS. 12/C and D show according to the present invention theadvantageously oblique inner ends of the divided endoscopic device innormal and in shifted positions, respectively,

FIG. 12/E shows according to the present invention the possibleelliptical cross section of the endoscopic device,

FIGS. 13/A and B show according to the present invention thelongitudinal sections of the divided endoscopic device advantageouslywith oblique inner ends in normal and in shifted positions,respectively,

FIGS. 13/C and D show according to the present invention theadvantageous cross sections of the divided endoscopic device,

FIG. 13/E shows according to the present invention the cross sections ofthe instrument with a trocar sleeve or a connected ring that areinsertable into the working channel of an endoscopic device,

FIGS. 14/A and B show according to the present invention the normal andthe shifted positions of the normal (straight) inner ends of the upperand lower endoscopic parts each containing two intact working channelsinside,

FIG. 14/C shows the common cylindrical end of the previous endoscopicdevice with two trocar shafts and with the articulating device,

FIG. 15 shows according to the present invention the already shiftedupper and lower parts of the divided endoscopic device with obliqueinner ends, each endoscopic parts containing two intact (non divided)working channels that are hermetically sealed at their outer ends, andthe two independent parts are connected together by a longitudinalsliding connection,

FIGS. 16/A, B and C show additional advantageous variations of theconnections of the trocar sleeves,

FIG. 17/A shows the non divided endoscopic device with an oblique orstep-form opened inner end,

FIG. 17/B shows the cross section of the previous device,

FIG. 17/C shows the oblique inner end of the non divided endoscopicdevice,

FIGS. 18/A and C show the device able to close the wound on a wall of ahollow organ,

FIG. 19/A shows the instrument within a step-form opened tube justpenetrating through the stomach,

FIG. 19/B shows the camera introduced through the small wound,

FIGS. 20/A, B and C show another advantageous method with the accesscatheter to penetrate through the wall of a hollow organ,

FIG. 21 shows a gall bladder operation by a laparo-endoscopic systemhaving a step-form opened inner end, the fixation possibilities of theinner and the outer ends of the system, and the anatomical landmarks,

FIG. 22 shows a SPLS (Single Port Laparoscopic Surgery) gall bladderoperation through an abdominal port by surgical instruments with rigidends and middle parts,

FIG. 23 shows a SPLS (Single Port Laparoscopic Surgery) gall bladderoperation performed with a laparo-endoscopic system having a rigid tubewith step-form opened inner end,

FIG. 24/A shows the laparo-endoscopic system with an oblique andstep-form opened inner end and with a protective sheath that isintroduced into the patient through a natural orifice,

FIG. 24/B shows the removal of the gall bladder by the help of thelaparo-endoscopic system throughout the protective sheath,

FIG. 25 shows an appendicectomy operation by a laparo-endoscopic systemhaving a step-form opened inner end, the fixation possibilities of theinner and the outer ends of the system, and the anatomical landmarks,

FIGS. 26/A and B show an appendicectomy operation performed with alaparo-endoscopic system having an oblique and step-form opened innerend and with an endoscopic stapler, and the removal of the appendixthroughout the protective sheath,

FIG. 27 shows the closure procedure of the wound on the wall of a holloworgan by the help of a tube having step-form opened inner end and acamera, and by the help of the wound closure device attached to thetube,

FIG. 28 shows the wound closure device with a camera attached to thetube that is turned around within the wound of a hollow organ during theclosure process,

FIG. 29/A shows the threads with locking elements that are insertedcircumferentially into the wound edges of the hollow organ, and theimplanting tube,

FIG. 29/B shows the threads with locking elements that are insertedaround a pathological lesion of a hollow organ, and the implanting tube,

FIG. 29/C shows the contracted wound edges pulled up into the tube bythe threads, and the elevated wound edges,

FIG. 30/A shows a laterally opening straight endoscopic stapleradvantageously with a control thread and a camera that is insertedthrough the mouth along the implanting tube,

FIG. 30/B shows the contracted and elevated wound edges or the elevatedpathologic lesion of the bowel wall that are pulled among the staplingsurfaces by the threads and the implanting tube, and also the controlthread under tension,

FIG. 30/C shows the closed wound of the hollow organ by a stapler, andalso the implanting tube and the removed tissue,

FIG. 30/D shows according to another possible solution of the endoscopicstapler with a control thread and a connecting groove,

FIGS. 31/A, B and C show a wound closure process with a laterallyopening curved endoscopic stapler,

FIG. 32/A shows a front opening straight endoscopic stapler bent at thearticulation having a control thread and a connecting groove,

FIG. 32/B shows the contracted and elevated wound edges or the elevatedpathologic lesion of the bowel wall that are pulled by the threads andthe implanting tube among the stapling surfaces of a front openingendoscopic stapler, that is bent at its articulation, and also has acontrol thread and a camera attached by sliding connection,

FIGS. 33/A and B show the excision of the tissue pulled into the staplerand also the stapled closure of the wall of the hollow organ, andfinally

FIGS. 34/A and B show the full excision of the pathological lesionlocated on the wall of a hollow organ and also the closure of the woundwith sutures by the help of a laparo-endoscopic system.

According to an advantageous embodiment hereof, the surgical instrument6 (e.g. FIG. 1/B) is inserted into the trocar sleeve 7, and the trocarsleeves 7 (e.g. FIGS. 3/A and B) are inserted into the partially ortotally flexible tube 28 (FIG. 9/A) or endoscopic device 66, 103 (FIG.15, 17). Advantageously the connections between the tube 28 or theendoscopic device 66, 103 and the trocar sleeves 7 and the surgicalinstruments 6 allow both longitudinal and rotational movements (e.g.FIG. 11). If required further accessory devices (e.g. protector sheath71—e.g. FIG. 15, wound closure device—FIG. 18, endoscopic stapler88—e.g. FIG. 30) could be attached to their inner or outer surfaces.Advantageously all connections allow longitudinal movement or slidingalong the longitudinal axis and rotation around the longitudinal axis,respectively.

As the FIGS. 1/B and C show, according to an advantageous embodiment ofthe surgical instruments 6, the surgical instrument 6 advantageouslyconsists of three parts: the partially flexible middle part 2 and thetwo telescopically extendable rigid inner 1 and outer 3 ends, and saidinner 1 and outer 3 ends are connected to the middle part 2 throughjoint-like articulations 4. Advantageously the segments of the middlepart 2 adjacent to the articulations 4 are also rigid. The cross sectionof the instrument 6 is advantageously circular.

Advantageously the outer 3 and the inner 1 ends of the instrument 6 aresimultaneously bendable at the articulations 4 relative to the middlepart 2 with the same rotational angle and in the same rotationaldirection (when the middle part 2 is in straight position the rotationalaxes of the outer 3 and inner 1 ends at the articulations 4 are parallelwith each other), as if the outer 3 and the inner 1 ends were thecomponents of one traditional laparoscopic instrument. The bending ofthe inner 1 and the outer 3 ends are executed advantageously only in onecommon plane (in case the middle part 2 is in straight position) andadvantageously through a pair of antagonistic wires 5, and said wiresextend opposite to one another from the inner end 1 throughout thearticulations 4 and the middle part 2 to the outer end 3. Of courseaccording to another embodiment the articulations 4 could be bendable inmore than one common plane utilizing more than one pair of antagonisticwires 5. It is obvious that any currently known technical solutions arealso acceptable to achieve the above described bending mechanism. Suchpossible solution could be a flexible or rigid pusher rod that is placedwithin the middle part 2 and is connected to both the outer 3 and theinner 1 ends. In fact the instrument 6 (FIG. 3/C) inside a trocar sleeve7 may have a function similar to the pushing rod, if the instrument 6 isresistant against compression.

There is a releasable ratchet mechanism 18 (FIG. 1/E) located at thearticulation 4 that connects together the middle part 2 and the outerend 3. The ratchet mechanism 18 with the locker 19 allows the fixationof the desired angle between the middle part 2 and the outer 3 and theinner 1 ends transiently or permanently.

The telescopic ends 1, 3 consist of rigid straight tubes, and said tubesare insertable into one another. The head 8 of the surgical instrument 6is located on the inner telescopic end 1, and advantageously it isconstructed similarly as the head of any recently used laparoscopicinstruments (including the camera as well). The handle 9 is situated onthe outer telescopic end 3 of the surgical instrument 6, andadvantageously it is also constructed similarly as the handle of anyrecently used laparoscopic instruments (including the camera as well).The opening and the closing movements of the handle 9 of the instrument6 control the function of the head 8 with the help of a motive wire 13that extends from the outer end 3 through the middle part 2 to the innerend 1.

The head 8 situated on the inner end 1 of the instrument 6 is rotatablearound the longitudinal axis (FIGS. 5 and 6/E). The rotation of the head8 is controlled by the rotation of the outer end 3 of the instrument 6,advantageously without the need to rotate the handle 9. The rotation ofthe handle 9 advantageously is independent from the rotation of the head8. Advantageously the head 8 located on the inner end 1 and the outerend 3 rotates with the same degree. The rotation of the head 8 and theinner end 1 by the outer end 3 is executed via the connected forcetransmission particles 12—said connections among the particles 12 resistto the torsion effects around the longitudinal axis as described before,or is executed via the flexible sheath 108 that also resist to thetorsion effects around the longitudinal axis. Of course any other knownsolutions are acceptable that allow rotation of the head 8.

In spite of the fact that the outer 3 and the inner 1 telescopic endsare separated form each other by the middle part 2, they move togethersimultaneously, as if they were the straight continuation of each other,similarly to the movements of the inner 1 and outer 3 ends of a straighttraditional laparoscopic instrument. When, for example, the outertelescopic end 3 is pushed to some extent, that is, its length isreduced, the length of the inner telescopic end 1 becomes simultaneouslyelongated with the same extent, and this works vice versa, of course.This movement is directed by the force transmission unit situated insidethe surgical instrument 6.

According to an advantageous embodiment this force transmission unit islocated inside the channel of the instrument 6 and advantageouslyconsists of ball shaped force transmission particles 12 (FIG. 1/B). Thechannel extends from the inner telescopic end 3 through the middle part2 to the outer telescopic end 3. The full length of the channel isfilled up with balls 12. The diameter of the ball is somewhat smallerthan the inner diameter of the channel. Advantageously there are holesin the middle of the balls 12, and the motive wire 13 travels throughthese holes from the handle 9 to the head 8. Advantageously the channelis provided with antifriction material. Advantageously the ball likeforce transmission particles 12 are able to pass easily through thechannels at the articulations 4. When the handle 9 of the instrument 6is pushed forward, the handle 9 push the last ball 12 in the channel ofthe outer telescopic end 3. The adjacent balls 12 transfer this pushingforce to one another, and at last the first ball in the channel of theinner end 1 pushes forward the head 8 of the instrument 6, resulting inthe elongation of the inner telescopic end 3. To execute the movement inthe opposite direction that is to reduce the length of the innertelescopic end 1, it is advantageous to utilize a wire that connects thetwo telescopic ends 1, 3 together, and for this purpose the motive wire13 is also acceptable. When pulling the handle 9 of the instrument 6,the outer telescopic end 3 becomes elongated and the wire 13—fixed tothe handle 9—simultaneously pull in the inner telescopic end 1. If thefree transmission is guaranteed, any other form distinct from the ballshape is suitable. The bendable connections among the force transmissionparticles 12, which are threaded by the motive wire 13, are designed toresist their compression along the longitudinal axis and to resist theirtorsion to each other around the longitudinal axis.

According to another advantageous embodiment the force transmission unitis a hydraulic unit 14 advantageously with an elastic capsule, and saidhydraulic unit 14 is located inside the channel described above (FIG.1/D). According to an advantageous embodiment, the hydraulic unit 14 hasthree parts: the inner 16 and the outer 17 ends and the middle part 15.The three parts of the hydraulic unit 14 communicate with one anotherand they form together one common cavity. This hydraulic unit 14 is aclosed system and the hydraulic fluid does not communicate with theouter environment, it only flows through the three parts of the commoncavity. The middle part 15 of the hydraulic unit is locatedadvantageously in the channel of the middle part 2 of the instrument 6,and their lengths are equal, and said middle part 15 of the hydraulicunit 14 is fixed to the channel in order to avoid shifting. The inner 16and the outer 17 ends of the hydraulic unit 14 are located inside thechannels of the inner 1 and the outer 3 telescopic ends of theinstrument 6. The inner 16 and the outer 17 ends of the hydraulic unit14 are advantageously designed to allow only longitudinal expansion orreduction along their longitudinal axis without any change in theirdiameter. The capsules of the ends 16, 17 of the hydraulic unit 14 areadvantageously able to move within the channels of the ends 1, 3 of theinstrument 6 along its longitudinal axis. One possible advantageoussolution regarding the ends 16, 17 of the hydraulic unit 14 would be theaccordion like folding of the walls of both ends 16, 17. When the outertelescopic end 3 is compressed longitudinally because the handle 9 ofthe instrument 6 is pushed, the accordion shaped outer end 17 of thehydraulic unit 14 becomes simultaneously compressed along itslongitudinal axis. Thereby the elevated pressure within the outer end 17of the hydraulic unit 14 is transferred through the fixed hydraulicmiddle part 15 to the inner hydraulic end 16 resulting in thelongitudinal expansion of the accordion folded inner hydraulic end 16that leads to the elongation of the telescopic inner end 1 as well.Advantageously the extent of the elongation and the extent of theshortening are equal. Along with the accordion folded design, a similarresult can be achieved, if the wall of the hydraulic unit 14 is made ofappropriately elastic material. To execute the movement in the oppositedirection in order to reduce the length of the inner telescopic end 1,it is advantageous to utilize a wire that connects the two telescopicends 1, 3 together, and for this purpose the motive wire 13 is alsoacceptable. When pulling the handle 9 of the instrument, the outertelescopic end 3 becomes elongated and the wire 13—fixed to the handle9—simultaneously pulls in the inner telescopic end 1.

Yet another possible design of the force transmission unit is a flexiblesheath 108 placed within the channel of the instrument 6, which,according to an advantageous solution, is a coiled spring or a plastictube (FIG. 1/I on drawing page 2/29). Advantageously the flexible sheath108 resists compression along the longitudinal axis and also resiststorsion around the longitudinal axis. Advantageously the flexible sheath108 has insulating properties. The flexible sheath 108 is back and forthslidable within the channel of the instrument 6, thereby the telescopicmovements of the outer 3 and the inner 1 ends could be executedsimultaneously, and because of the flexibility of the sheath 108 itmoves easily through the articulations 4 as well. The motive wire 13 isinside the flexible sheath 108.

On the middle part 2 of the instrument at least one connecting ring 10is placed advantageously to connect between the tube 28 and theinstrument 6 (FIGS. 1/H and 2/C). The instrument 6 is easily rotatablewithin the ring 10. There is a connecting groove 11 formed on the outersurface of the ring 10. According to another advantageous solution, athread 23 with needle 24 is connected to the ring 10 which helps to fixof the middle part 2 of the instrument 6 to any part of the abdominalwall 41 (FIGS. 2/D and 8).

According to another advantageous embodiment the instrument 6 isattachable to the tube 28 through a simple trocar sleeve 7 (FIGS. 4/Aand 4/F). There is a sliding connection 29 between the tube 28 and thetrocar sleeve 7, and the middle part 2 of the instrument 6 is located inthe trocar sleeve 7. The middle part 2 of the instrument 6 isadvantageously longer than the trocar sleeve 7. The instrument 6 isrotatable and back and forth slideable within the trocar sleeve 7.Advantageously there is a valve 22 and an airtight ring 21 on the outerend 3 of the trocar sleeve 7 (FIG. 4/E). The cross section of the trocarsleeve 7 could have a sector-like form. The trocar sleeve 7 could berigid or flexible.

According to another advantageous embodiment the instrument 6 has threemain components: the partially flexible middle part 2 and the rigidtelescopically extendable outer 3 and inner 1 ends which are connectedto the middle part 2 through joint-like articulations 4 (FIG. 2/B). Theforce transmission system is the same as described above. The instrumenthas no wire to execute the bending of the telescopic ends 1, 3.According to this solution the instrument 6 is connected to the tube 28with such a trocar sleeve 7 which has a partially or totally flexiblemiddle part 2, and rigid outer 3 and inner 1 ends that are connected tothe middle part 2 through articulations 4 (FIG. 2/A). The bending of theouter 3 and the inner 1 ends are executed by the antagonistic wires 5located within the trocar sleeve. Advantageously the ratchet mechanism18 is mounted on the outer articulation 4. There is advantageously avalve 22 and an airtight ring 21 located on the outer end 3 of thetrocar sleeve 7.

The length of the middle part 2 of the trocar sleeve 7 is advantageouslylonger than the length of the tube 28. There is a sliding connection 29between the trocar sleeve 7 and the tube 28. The length of the middlepart 2 of the instrument 6 is advantageously longer than the length ofthe middle part 2 of the trocar sleeve 7. The instrument 6 within thetrocar sleeve 7 is easily moveable along the longitudinal axis and alsorotateable around the longitudinal axis.

According to another advantageous embodiment the instrument 6 consistsof three main parts: the flexible middle part 2 and the non-telescopicrigid outer 26 and inner 25 ends (FIG. 3/C). The motive wire 13 issituated inside the instrument 6. There is no additional forcetransmission unit within the instrument 6, as this transmission functionis executed by the middle part 2 and the two rigid ends 25, 26.

An instrument 6 constructed this way is connected to the tube 28advantageously through a trocar sleeve 7 which has a partially ortotally flexible middle part 2 and with articulations 4 connected rigidtelescopic outer 3 and inner 1 ends (FIGS. 3/A and 3/B). Thesimultaneous bandings of the articulations 4 as described earlier areexecuted by the antagonistic wires 5 situated within the wall of thetrocar sleeve 7. Similarly, the ratchet mechanism 18 could be formed onthe outer articulation 4 (FIG. 3/E). The simultaneous elongation andshortening of the telescopic ends 1, 3 of the trocar sleeve 7 are theresults of the forward or backward movements of the instrument 6 withinthe trocar sleeve 7. Advantageously there is a sliding connection 29between the trocar sleeve 7 and the tube 28, which allows free movementsalong the longitudinal axis. Advantageously the sliding connection 29 isaccomplished by at least one connecting ring 10 situated on the middlepart 2 of the trocar sleeve 7, and said ring 10 is freely rotateablearound the middle part 2 (FIG. 3/D). Advantageously the ring 10 has aconnecting groove 11 that is connected with the rail 50 mounted on theinner surface of the tube 28 (e.g. FIG. 10). There is an airtight valve22 and a ring 21 on the outer end 3 of the trocar sleeve 7 (FIGS. 3/Aand 3/B).

According to an advantageous embodiment, the trocar sleeves 7 areconnected to one another through sliding connections 29 mountedlongitudinally on their outer surfaces, and each trocar sleeve 7 isconnected with the two adjacent trocar sleeves 7 to form a cylindricalarrangement (FIG. 4/B). Advantageously four connected trocar sleeves 7are sufficient to perform most surgical interventions. In this case thecross section of each connected trocar sleeve 7 is advantageously aquarter sector, and they together make a full circle (FIG. 4/G), therebythe common outer cylindrical form makes a gentler intervention possible(e.g. when penetrating through the gastric wall 39). The slidingconnections 29 (a groove 11 or a rail 50 fitting to one another) aresituated on the flat superficia of the trocar sleeves 7, and saidsliding connections 29 allow the longitudinal movements of the trocarsleeves 7 relative to each other. This kind of trocar sleeve 7 has twoflat superficia, one of them has the groove 11 and the other has therail 50 that fits to the groove 11. The cross sections of the workingchannels 27 of the trocar sleeves 7 are advantageously rounded. Thiskind of trocar sleeves 7 could be partially or totally flexible orrigid. The inner end 3 of the trocar sleeves 7 may have an oblique planewhich makes the penetration through the stomach wall 39 easier (e.g. ina similar case as in FIG. 19/A).

According to this possible solution, to the trocar sleeves 7 with sectorcross sections, and with rigid outer 3 and inner 1 telescopic ends areadvantageously attached through articulations 4 (FIGS. 4/C and 4/D).Advantageously the cross sections of the telescopic ends 1, 3 are round,and said ends 1, 3 are rotatable relative to the middle part 2 aroundthe longitudinal axis. In this case there is no force transmission unitto actuate the telescopic ends 1, 3. This telescopic function isexecuted by the surgical instrument 6 located within the working channel27 of the telescopic trocar sleeve 7, and said instrument 6 has aflexible middle part 6 and rigid outer 26 and inner ends 25 (FIG. 3/C),and is able to move longitudinally forth and back within the workingchannel 27. The simultaneous bending of the telescopic ends 1, 3 attheir articulations 4 are advantageously directed by a pair ofantagonistic wires 5 located within the trocar sleeve 7. At the outerend 3 of the trocar sleeve 7 there is an airtight valve 22 and a sealingring 21.

There are several other possible solutions to connect the trocar sleeves7 together.

According to an advantageous embodiment, the additional trocar sleeves 7are connected to the outer surface of a double trocar sleeve 99 throughsliding connections 29 (FIG. 16/A). Advantageously the trocar sleeves 7are attached to the junction part of the double trocar sleeve 99. Inaddition further connecting grooves 11 or rails 50 could be formed onthe outer surfaces of the double trocar sleeve 99 or on the additionallyattached trocar sleeves 7 to connect them e.g. with a thread 23, stick51 or rod 61 to ensure their fixation to the abdominal wall 41 (similarto FIGS. 8 and 11).

According to another advantageous embodiment, the trocar sleeves 7 areconnected to the outer surface of a trocar guide 98 through slidingconnections 29 (FIG. 16/B). The connecting grooves 11 or rails 50 aremounted on the outer surface of the trocar guide 98. Inside the trocarguide 98 a smaller diameter working channel 27 could be situated, whichcould be used to insert e.g. a ballooned access catheter 104 (FIGS.20/A, 20/B and 20/C). The inner end of the trocar guide 98 isadvantageously sharp.

According to a further advantageous embodiment the additional trocarsleeves 7 are attached to a central trocar sleeve 7 through slidingconnections 29 (FIG. 16/C). Advantageously the outer cross section ofthe central trocar sleeve 7 is optional, while the cross section of theworking channel 27 inside the central trocar sleeve 7 is round.Advantageously there could be further channels located inside thecentral trocar sleeve 7, e.g. gas 64 or suction-irrigation 65 channels.The connecting grooves 11 or the rails 50 are mounted on the outersurface of the central trocar sleeve 7.

A tube 28 is not necessary to introduce the connected trocar sleeves 7.The trocar sleeves 7 could be fixed to the abdominal wall 41 transientlyor permanently with a ring 10 located advantageously near to the innerend 1 of the middle part 2 (e.g. similar to FIG. 8). The fixation ispossible with a thread 23 with a needle 24, or with a rigid stick 51 orwith a control rod 61 (e.g. FIG. 2/D or 11). The connected trocarsleeves 7 within the ring 10 are free to move along and to rotate aroundthe longitudinal axis, respectively. In case no tube 28 is used,advantageously there could be connecting grooves 11 or rails 50 formedon the outer surfaces of the trocar sleeves 7 to allow the connection ofother endoscopic devices 30.

The trocar sleeves 7 connected together by sliding connections 29 (FIGS.4/B, C, D and G) are also insertable into the abdominal cavity orfixable to the abdominal wall 41 by the help of a partially or totallyflexible simple tube 28 (FIG. 4/A). In this case there is no groove 11or rail 50 formed inside the tube 28, they are formed only on the outersurface of the tube 28 (FIG. 4/F). The inner end opening 31 of the tube28 may have a normal 102 (i.e. flat), oblique 101 or step-form 100 shape(FIGS. 4/A and 9/A, B and C). There may be a thread 23 (FIG. 2/D), stick51 (FIG. 4/A) or rod 61 (FIG. 11) connected to the outer surface of theinner end 52 of the tube, each of them allowing to fix the tube 28 tothe abdominal wall 41. The stick 51 may have a connecting foot 58 thatfits into the advantageously longitudinally situated connecting groove11 on the outer surface of the tube 28, and said connecting foot 58 isslideable within the groove 11 (FIG. 10). In this case the inner end 52of the tube 28, which is fixed to the abdominal wall 41 with the stick51, is slideable back and forth by the help of the connecting foot 58,thereby allowing the proper adjustment of the inner end 52 over thedesignated operating field. At the same time by the help of the rigidstick 51 or rod 61 the inner end 52 of the tube 28 is easilymaneuverable to any desired part of the intraabdominal cavity, or isfixable in any desired location and position, respectively (FIG. 11). Ofcourse several other outer endoscopic devices 30 (e.g. wound closuredevice, camera 44, forceps, etc.) could be connected to the groove 11located on the outer surface of the tube 28 (e.g. FIG. 27).

In the following part hereof, the tubes 28 and the endoscopic devices66, 103 housing surgical instruments 6 and/or trocar sleeves 7 will bediscussed with their possible advantageous embodiments.

The tube 28 refers to a solution, which has a long cylindrical bodyadvantageously with one single lumen inside, and into this lumensurgical instruments 6, trocar sleeves 7 or other accessory devicescould be inserted (FIGS. 4/A and 9/A).

According to the simplest advantageous solution both ends 52, 53 of thetube 28 are normal (i.e. straight) 102, and its cross section is roundor elliptical (FIG. 4/A). Advantageously the outer 53 and the inner ends52 of the tube 28 could be rigid and the middle part 2 could be flexibleor could be rigid (similar to FIG. 23) if required. The inner diameterof the tube 28 makes it possible to insert more than one—advantageouslyfour—trocar sleeves 7. The inner surface of the tube 28 could becompletely smooth, or according to an advantageous embodiment, may havelongitudinal connecting grooves 11 or rails 50 on the inner surface(FIG. 9/F). Advantageously there could be longitudinal connectinggrooves 11 or rails 50 also on the outer surface of the tube 28. Athread 23 (FIG. 2/D), a stick 51 (FIG. 4/A) or a rod 61 (FIG. 11) couldbe attached to the outer surface of the tube 28 advantageously at theinner end 52 region. There is advantageously a joint-like articulation 4between the inner end 52 and the middle part 2 of the tube 28 (FIG.9/A). The inner end 52 is bendable at the articulation 4 relative to themiddle part 2 by the help of a pair of wires 5 that extendlongitudinally throughout the tube 28, and an articulating device 54mounted on the outer 53 end of the tube 28. The opening 31 of the innerend 52 of the tube 28 could be normal 102 (i.e. straight) FIG. 4/A,oblique 101 (FIG. 9/B) or step-form 100 (FIGS. 9/A and C). The inneropening 31 is straight 102 if the plane of the inner opening 31 isperpendicular to the longitudinal axis of the tube 28. The inner opening31 is oblique 101 if the plane of the inner opening 31 is notperpendicular to the longitudinal axis of the tube 28. The inner opening31 is step-form 100, if the straight 102 or oblique 101 opening iscombined together with an opening located on the side of the inner end52 of the tube 28 (the plane of the side opening is advantageouslyparallel with the longitudinal axis). The step-form opening 100 has agreater advantage because it significantly expands the size of theinterventional area and assures the easier maneuvers.

The greater the size of the opening 31 of the inner end 52 facing towardthe operation field, the greater is the freedom of movements/maneuversof the instruments 6. This opening 31 area could be readily enlarged tothe desired size by additionally increasing the size of the side openingcomponent. An independent opening could be situated also on the wall ofthe middle part 2 of the tube 28. Advantageously there are anarticulating device 54, a gas connection 55, and an arbitrary detachableor attachable airproof cap 47, closing the outer opening 32, mounted onthe outer end 53 of the tube 28 (FIGS. 9/A and E). The cap 47 isattached to the outer end 53 by means of screw-threads or by any otherknown airproof connections. There are cap openings 48 with valves 22 onthe cap 47.

In case of the SPLS procedures advantageously the whole tube 28 is rigid(FIG. 23).

In case of either solution referred above an optional external fixateurdevice 42 could be attached (e.g. FIG. 21, 23 or 25) to the outer end ofany instrument 6, trocar sleeve 7, tube 28 (e.g. FIGS. 4/A and 9/A) orendoscopic device 66, 103 (e.g. FIG. 15 or 17/A), and said externalfixateur device 42 is able to fix the outer end transiently orpermanently in a desired position.

In case of either solution above the inner end of any instrument 6,trocar sleeve 7, tube 28 or endoscopic device 66, 103 could be fixed viaa thread 23 (FIG. 2/D), or a stick 51 (FIG. 4/A) or a control rod 61(FIG. 11), being attached to the inner end, to the abdominal wall and/orto an external fixateur device 42.

The endoscopic device 66, 103 refers to a solution, which has a longcylindrical body advantageously with round or elliptical cross sectionand with more than one working channels 27 inside (FIGS. 12, 13, 14, 15and 17). The elliptical cross section is advantageous, because thedistance between the two lateral working channels 27 could be larger(FIG. 12/E) which allows easier maneuvers to the instruments 6 withinthese two working channels 27. Advantageously there could be connectinggrooves 11 or rails 50 formed on the outer surface of either type ofendoscopic device 66, 103 in order to establish additional externalconnections (e.g. with a thread 23, stick 51, control rod 61, stomachclosure device, etc.). According to an advantageous embodiment therecould be an articulation 4 formed at the inner end of either type ofendoscopic device 66, 103, and said articulation 4 is bent by a pair ofwires 5 and an articulating device 54. This pair of wires 5 extendsthrough the entire endoscopic device 66, 103 and is connected to thearticulating device 54 located at the outer end of the endoscopic device66, 103. The inner and the outer ends of either type of endoscopicdevice 66, 103 are advantageously rigid and the middle part could beflexible or rigid. Either endoscopic device 66, 103 may have optionallya gas channel 64 and a suction-irrigation channel 65.

According to a possible advantageous solution the endoscopic device 66is divided (FIGS. 12 and 15). In this case the endoscopic device 66 ispartially or totally divided into two parts (upper and lower parts) by aplane that is advantageously parallel with the longitudinal axis. Thetwo parts are connected together by sliding connection 29, and they areoptionally movable back and forth along their longitudinal axis relativeto each other. The dividing plane may divide the working channel 27inside the endoscopic device 66 into two complementary divided workingchannels 70 (FIG. 12). When the two divided parts of the endoscopicdevice 66 are shifted longitudinally relative to each other, the dividedworking channels 70 become free at their inner ends. The instruments 6bent at their inner articulations 4 are easily movable back and forthwithin the free part of the divided working channels 70 with or withoutthe trocar sleeves 7. The free part of the divided working channel 70 isadvantageous because it allows the telescopic inner end 1 and head 8 ofthe instrument 6—i.e. the part that is distal to the inner articulation4- to exit from the free part of the divided working channel 70 alongits full length in order to reach the interventional area. The length ofthe free parts of the divided working channels 70 could be changedoptionally (increase or decrease) by shifting the two divided endoscopicparts longitudinally relative to one another (FIG. 12). According to andadvantageous arrangement of the four working channels 27, the planedividing the endoscopic device 66 into two longitudinal parts alsodivides longitudinally two opposite working channels 70. The other twoworking channels 27—advantageously the upper and the lowerchannels—remain intact. The normal 102 (FIG. 12/A) or oblique 101 (FIG.12/C) inner ends of the divided endoscopic device 66 could betransformed into a step-form 100 (FIGS. 12/B and D) inner end by thelongitudinal shift of the two parts (advantageously only the upper partor only the inner part) relative to one another, in order to achieve theadvantages discussed above.

According to a possible advantageous embodiment the outer end of thedivided endoscopic device 66 is rigid. The rigid end of the upper partof the device 66 is completed to a full cylinder, in such a way, thatthe rigid end of the slideable lower part is also inside the cylinder(FIG. 12/A). The outer end completed to a full cylinder is airtight andhas advantageously four air proof openings 48 with valves 22, and saidopenings 48 are the inlet openings of the intact 27 or divided 70working channels situated within the endoscopic device 66. The airtightclosure of the cylindrical common end 67 may be also achieved by anoptionally securable cap 47 with airtight inlet openings 48 and valves22 (e.g. similar to FIG. 9/E).

Advantageously the trocar shaft 68—i.e. the rigid tube-like continuationof the lower part—exits the common cylindrical end 67 through the lowerouter opening 48 (FIGS. 13/A and B). The trocar shaft 68—provided with avalve 22—is the external continuation of the intact working channel 27located inside the lower endoscopic part, and said trocar shaft 68,which extends through the lower outer opening 48, has an ear-like handle69 at the outer end that helps to move the lower endoscopic partlongitudinally back and forth. Advantageously the trocar shaft 68 isshifted in and out through the lower outer opening 48 of the commoncylindrical end 67 by the help of the ear-like handle 69, whichconsequently means the longitudinal back and forth movement of the innerend of the lower endoscopic part. Thereby the size of the step-forminner opening 100—and consequently the size of the interventionalarea—is optionally adjustable.

According to another possible solution, the plane dividing theendoscopic device 66 parallel with the longitudinal axis does not divideany of the working channels 27. Advantageously both the upper and thelower endoscopic parts contain two intact working channels 27 (FIG. 14).In this case the shape of the outer end of the endoscopic device couldbe a common cylinder 67 similarly to the previous solution, except thatnow two rigid trocar shafts 68, which are the external continuation ofthe two working channels 27 of the lower endoscopic part, exit troughthe two lower outer openings 48 of the common cylindrical end 67.

According to another possible solution, the outer ends of the dividedendoscopic device 66 are similarly divided as the inner ends, and bothouter ends are hermetically sealed (FIG. 15). The upper and lower outerends have airtight outer openings with valves 22. In this case eitherendoscopic part—the upper and the lower endoscopic parts are connectedtogether by sliding connection 29—could be removed from the patient andcould be replaced by a larger endoscopic tool (e.g. an endoscopicstapler 88 similarly to FIG. 26/A), or through the space of the removedendoscopic part tissue or organ specimens could be removed as well.

According to another advantageous embodiment the endoscopic device 103is solid and undivided (FIG. 17). The opening of the inner end of thedevice could be normal 102, or oblique 101 or step-form 100. In case theinner end has a step-form opening 100 there could be one or more workingchannels divided 70 partially advantageously only at the inner endregion, in order to achieve the above detailed advantages.Advantageously the upper and the lower working channels 27 are intact(i.e. undivided) while the other working channels 70 on both sides aredivided at their inner ends. Of course a pair of intact (i.e. undivided)upper and a pair of intact lower working channels 27 arrangement is alsopossible. The outer end of the undivided endoscopic device 103 ishermetically sealed and there are airtight outer openings with valves22, and said outer openings are the inlets of the working channels 27,70.

Inside the divided working channels 70 of any type of endoscopic device66, 103 there are sliding connections 29 (e.g. sliding rim 74,connecting groove 11 or rail 50) allowing the proper attachment andfixation, and the longitudinal back and forth movement of the insertedtrocar sleeve 7 or instrument 6 (e.g. FIGS. 13/C, D and 17/B). Thisconnecting components (e.g. sliding rim 74, connecting groove 11 or rail50) are connected to the connecting components (e.g. groove 75 on FIG.13/E) of the instruments 6 or the trocar sleeves 7.

The outer end of any type of tube 28 or endoscopic device 66, 103 mayhave a cone shape 105 (FIGS. 21 and 25). This is advantageous because itallows the easier handling of the outer ends 3 of the instruments 6

Any type of the previously mentioned instruments 6, trocar sleeves 7,tubes 28 or endoscopic devices 66, 103 may have light sources 106, e.g.LEDs advantageously on their inner ends (FIG. 9/A). More light sources106 result in better illumination of the operating field.

Any kind of combination of the previously mentioned laparo-endoscopicsystem could be able to perform surgical interventions inside the holloworgans lumen (e.g. excision of pathological lesions, wound closure,feeding tube insertion). In this case an inflatable balloon 45 helps tosecure the device (e.g. instrument 6, trocar sleeve 7, tube 28 orendoscopic device 66, 103), which is placed at the inner end region ofthe device (FIG. 34). Advantageously the balloon is slideable on thedevice, and its outer diameter is larger than the diameter of theesophagus 38 or other hollow organ 39, respectively.

In any of the previously described instrument 6—trocar sleeve 7—tube 28or endoscopic device 66, 103 system, or instrument 6—trocar sleeve 7system, or instrument 6—tube 28 or endoscopic device 66, 103 system theinserted instruments 6 are able to reliably reproduce allthree-dimensional laparoscopic maneuvers by the help of bandings,rotations and telescopic movements.

Any type of the previously described instruments 6, trocar sleeves 7,tubes 28 or endoscopic devices 66, 103 may have a disposable or areusable design.

Any type of the previously described instruments 6, trocar sleeves 7,tubes 28 or endoscopic devices 66, 103 may have a design allowing theirdisassembling, cleansing and reassembling.

Hereinafter come the descriptions of the accessory devices.

The first such accessory device could be a protective sheath 71attachable to the outside of connected trocar sleeves 7, tube 28 orendoscopic device 66, 103 (FIGS. 12/A and B). The protective sheath 71is advantageously cone shaped and is made of a strong clingfilm-likematerial, that on the outer end has a connecting ring 73 or tube 97—ableto connect airtight to the outer end 53 of a tube 28 or an endoscopicdevice 66, 103—, and on the inner end it has a self-expandable ring 72.The protective sheath 71 covers the tube 28 or the endoscopic device 66,103. The protective sheath 71 is inserted via a natural orifice into theabdominal cavity through the wound 40 on the wall of a hollow organ 39advantageously in a rolled position over the tube 28 or the endoscopicdevice 66, 103. When the protective sheath 71 enters the abdominalcavity, the expanding cone shaped inner end with the self-expandablering 72 and the contracting wound 40 around the protective sheath 71prevent to escape the gas from the insufflated abdominal cavity (e.g.FIG. 24/A). In addition the protective sheath 71 protects the wall ofthe hollow organs 39 and the adjacent area against the injuries causedby the moving instruments 6, and prevents the contact with thecontaminated secretions, or with the diseased tissues or organs. Thecone shaped inner end (i.e. the inner end has a larger circumference)allows to remove the tissues or organs easier. Of course any other shapeof the protective sheath 71 could be among the possible solutions.

The second such accessory device could be an endoscopic balloon tubewith independently inflatable balloons 45, which could be placedadvantageously on the inner end region of the connected trocar sleeves7, tube 28 or endoscopic device 66, 103 (FIGS. 9 and 19/A). This device56 is placed into the wound 40 on the wall of a hollow organ 39 (similarto FIG. 22), in order to prevent gas leakage. When the endoscopicballoon tube 56 is already inserted, the air ducts 57 of the balloons 45extend over the natural orifice.

The third such accessory device could be an access catheter 104, thatenables to create a wound opening 40 on the wall of a hollow organ 39(e.g. the stomach) during the access phase (FIGS. 20/A, B and C). Thecatheter 104 could be inserted into any suitable working channels 27,70. There is an electric unit 76—that is able to cut or coagulatetissues—mounted on the inner end advantageously on the tip of thecatheter 104, said electric unit 76 has an electrical wiring extendingalong the catheter 104, and said electrical wiring is connectable to anelectric power supply. The electric unit 76 is slightly recessed withinthe tip of the catheter 104 in order to avoid the direct contact withextended tissue areas. There are two consecutive balloons 77, 78 on thecatheter 104. The one 77 closer to the inner end has advantageously anumbrella-like shape characteristically with a diameter—that isperpendicular to the longitudinal axis—larger than that of the tube 28or the endoscopic device 66, 103. The next one is the dilating balloon78 that has advantageously a cylinder-like shape and its diameter issmaller than that of the tube 28 or the endoscopic device 66, 103. Theballoons 77, 78 are independently inflatable or deflatable, and theirair ducts extend over the outer end of the tube 28 or the endoscopicdevice 66, 103.

The fourth such accessory device could be a wound closure deviceallowing the closure of a wound 40 created on the wall of a hollow organ39 (FIG. 18). According to an advantageous embodiment the wound closuredevice consists of an implanting tube 85, an implanting sheath 82,locking elements 84, threads 23 and an implanting rod 83. The groove 11or rail 50 on the outer surface of the implanting tube 85 could beconnected with sliding connection 29 to the rail 50 or groove 11 on theouter surface of the trocar sleeve 7, tube 28 or endoscopic device 66,103. There are locking elements 84 on the inner end of each thread 23and there is one fixing knob on their outer ends. The locking elements84 are inside the implanting sheath 82, and the sheath 82 with thethreads 23 are inside the implanting tube 85. The inner end of theimplanting sheath 82 is sharp and there is a longitudinal split 86 onthe side of the sheath 82, and there is an implanting rod 83 locatedabove the locking elements 84. The locking elements 84, the implantingrod 83, the implanting sheath 82, the threads 23 and the implanting tube85 are moveable to each other or to a trocar sleeve 7, tube 28 orendoscopic device 66, 103, respectively. The implanting rod 83, theimplanting sheath 82 and the implanting tube 85 are advantageouslyflexible.

The fifth such accessory device could be assembled advantageously byrigid components, and allows the optional fixation of the outer and theinner ends of a trocar sleeve 7, tube 28 or endoscopic device 66, 103(e.g. FIGS. 21, 23 and 25). One end of this fixateur device 42 is fixedindependently from the patient, e.g. to the operating table. One type ofthe external fixateur device 42 could be suitable to fix the thread 23,or stick 51 or rod 61 connected to the outer surface of the inner ends,while another type of the device 42 is suitable to fix the outer ends.The shape, the angle and the position of the fixateur device 42 could besecured or changed optionally. The fixation of the inner end makespossible to simultaneously lift the abdominal wall 41. In addition, thefixation of the inner end to the abdominal wall 41 could be executed bythe help of a magnetic device 107 (FIG. 23).

The sixth such accessory device could be a modified endoscopic stapler88 (FIG. 30-32). Advantageously the head 89 of the stapler 88 is rigidand the body 90 is partially or totally flexible. The head 89 and thebody 90 are connected together advantageously by an articulation 4. Thestapling surface 93 of the head 89 is advantageously perpendicular orparallel to the longitudinal axis of the device 88, but any otherinclination angle is possible. There is a control thread 91 locatedbetween the free ends of the stapling surfaces 93, and said controlthread 91 could be optionally tensioned or relaxed. The thread 91 issituated within the channel 92 that extends throughout the head 89 andthe body 90 of the device 88. The end of the thread 91 extends over theouter end of the stapler 88. When the control thread 91 is tensioned thedesired part of the tissue is directed among the stapling surfaces 93.Under full tension the thread 91 supports the parallel closure of theadjustable jaw 95 of the stapler head 89. Advantageously there may be aworking channel 27 inside, or a groove 11 or rail 50 on the outersurface of the body 90 of the stapler 88 and said groove 11 or rail 50allows the connection of an accessory device 30 (e.g. a trocar sleeve 7,a camera 44, a forceps, etc.). The stapling surfaces 93 may havestraight, curved, wavy or any other recently known shape. The diameterof the stapler 88 is preferably smaller than the inner diameter of thetube 28 (e.g. FIG. 26/A).

The functions of the laparo-endoscopic system which according to thepresent invention is developed to accomplish all steps of the newsurgical interventions (access, surgical intervention, and closure) ofNOTES (Natural Orifice Transluminal Endoscopic Surgery), SPLS (SinglePort Laparoscopic Surgery) and IE (Interventional Endoscopy) are asfollows:

1. Access

Before starting the operation the laparo-endoscopic device is assembled.

According to an advantageous solution, the protective sheath 71 isplaced over the tube 28 and first it is attached to the outer surface ofthe tube 28 (e.g. FIG. 9/A), then it is rolled over the body of the tube28, finally a part of the expandable ring 72 is pulled into the inneropening 31 of the tube 28 by the help of an inserted instrument 6. Thetrocar sleeves 7 are introduced into the tube 28 by the help of slidingconnections 29. A camera 44 is placed into the working channel 27 of thelower trocar sleeve 7 (FIGS. 19 and 20), and the access catheter 104into the upper trocar sleeve 7. Thereafter the appropriately assembledflexible device system is introduced through the patient's naturalorifice, actually through the mouth and the esophagus 38 into thestomach 39. It is advantageous to create the opening 40 on the anteriorwall of the stomach 39. For this reason it is advantageous to use a tube28 with a step-form opened 100 rigid inner end 52, and said inner end 52could be bent at the articulation 4 perpendicularly toward the wall ofthe stomach 39 by the help of an articulating device 54 and wires 5. Thetip of the inner end 52 is pushed against the stomach wall 39, and thenthe access catheter 104 is pushed forward within the upper trocar sleeve7 (FIG. 20). By activating the electric unit 76 within the tip of theaccess catheter 104, the forward moving catheter 104 passes through thestomach wall 39 at the desired point due to the developing thermaleffect. Then the catheter 104 is pushed forward until the umbrella-likeprotective balloon 77 enters the abdominal cavity. At this point theprotective balloon 77 is inflated, and it is pulled against the outersurface of the stomach wall 39 by pulling the whole catheter 104outward. In this position the dilating balloon 78 is just in the stomachwall 39. Now the dilating balloon 78 is insufflated to reach a diameterthat is less than the diameter of the tube 28, then the balloon 78 isdesufflated, thereafter the step-form opened 100 inner end 52 of thetube 28 with gradually increasing diameter is pushed through the dilatedwound 40 into the abdominal cavity until the expandable ring 72 of therolled protective sheath 71 enters the abdominal cavity. Then theexpandable ring 72 is expelled out of the inner end 52 of the tube 28into the abdominal cavity with an instrument 6, and so the inner openingof the advantageously cone-shaped protective sheath 71 expands, and theprotective sheath 71 is compressed to the tube 28 by the wound (FIG.24/A). These two effects prevent gas leakage through the wound opening40. The expandable ring 72 prevents the inadvertent removal of theprotective sheath 71. The airtight connecting ring 73 or tube 97situated on the outer end of the protective sheath 71 prevents gasleakage at the outer end of the device system. The outer ends of thetrocar sleeves 7, tubes 28 or endoscopic devices 66, 103 are sealedhermetically.

After the inner end of the device system is inserted into the abdominalcavity the protective balloon 77 is also desufflated, and the accesscatheter 104 is removed out of the trocar sleeve 7. The insufflatedprotective balloon 77 that is pulled toward the inner end 52 of the tube28 during the access procedure protects the adjacent organs and tissuesagainst inadvertent injuries.

According to another version of the access procedure, the head 8 of aninstrument 6 is first passed through the stomach wall 39. Through thesmall created opening 40 a camera 44 is inserted to check the abdominalcavity (FIG. 19). Once the wound 40 area is controlled, the oblique 101and step-form 100 opened inner end 52 is passed gently through thestomach wall 39 following the camera 44, thus the wound 40 is dilatedgradually.

The access procedure is the same if an endoscopic device 66, 103 is used(e.g. FIGS. 12, 15 and 17).

When connected trocar sleeves 7 are introduced into the stomach 39, thesystem is directed toward the anterior stomach wall 39. Only onetelescopic inner end 1 is passed through the stomach wall 39 by the helpof an access catheter 104 or a camera 44, and then the procedure followsthe previously described steps.

An endoscopic balloon tube 56 could be attached to the system instead ofa protective sheath 71 as well (FIG. 19/A). As soon as the inner endenters the abdominal cavity, the outer balloon 45 is insufflated throughthe air duct 57 and then the system is pushed inward until the outerballoon 45 hits inside the stomach wall. At this point the inner balloon45 is also insufflated through an additional air duct 57. The twoballoons 45 fix the stomach wall 39 at the wound opening 40. Theendoscopic balloon tube 56 is slidable.

In case of an SPLS intervention the access procedure is performed viathe navel, advantageously similarly to the laparoscopic technique. Asmall umbilical incision is made and under direct eye-control alaparo-endoscopic system is inserted into the abdominal cavity. Thissystem consists of advantageously rigid trocar sleeves 7, rigid tube 28or endoscopic device 66, 103, and is also provided with a protectivesheath 71 or an abdominal port 81 (FIGS. 22 and 23). It is enough to fixthe outer end of the rigid system to an external fixateur 42.

2. Operation

This is the most important part of the whole intervention: to remove orto cure the diseased organs or tissues. The procedure performed with thelaparo-endoscopic system is similar to the well developed laparoscopictechnique. The inner end 52 of the device system is fixed above theoperation field through the abdominal wall 41 to an external fixateur 42(FIGS. 21 and 25) by the help of a thread 23 (FIG. 2/D), a stick 51(FIGS. 4/A and B) or a control rod 61 (FIG. 11). The abdominal wall 41could be lifted with the fixed inner end 52, thereby preventing thecollapse of the abdominal cavity over the operation field in case of agas leakage, and that makes the intervention much safer. The outer end53 of the system is fixed to another external fixateur 42. It isadvantageous, if the appropriately flexible middle part 2 of the systemis bent only slightly. The positions of the instruments 6, which areinserted through the working channels 27, are adjusted by the help ofthe articulations 4, the telescopic ends 1, 3, the sliding connections29 or the control rod 61. The inner 1 and the outer 3 ends of theinstrument 6 inside the tube 28 are moving similarly as the inner andouter components of a traditional laparoscopic instrument (with the onlydifference that they are separated by the middle 2 part), thus theintervention could be performed similar to the laparoscopic technique,where one single instrument 6 is controlled by only one hand (e.g. gallbladder operation 34 or appendicectomy 80—FIGS. 21 and 25). If the sizeof the operation field is changed during the procedure, the position ofthe inner end 52 could be also adjusted, depending on the type of thefixation. In case of a thread 23 or a stick 51 the position could bechanged by stitching through the abdominal wall 41 at another point. Itis easier to use a control rod 61 (FIG. 11) because it is strong andrigid enough to simply move the inner end 52 of the device system froman earlier position to a newer one. The advantage of the control rod 61could be increased, if it is inserted into the abdominal cavity throughthe umbilicus 60 (advantageously by the visual control of the camera 44of the device system) and is attached to the inner end 52 of the tube28. With this method it is possible to deliver the inner end 52 of thesystem to any area of the abdominal cavity and to fix it in the newposition, thereby even the extending operations could be performedwithout creating any additional wounds. This technique makes it possibleto perform any kind of interventions within the body cavities.

In case of appendicectomy, the appendix 80 could be removed by the helpof an endoscopic stapler 88 (FIG. 26/A). The endoscopic stapler 88 couldbe inserted through the empty space of the tube 28 created by theprevious removal of two adjacent trocar sleeves 7. The stapler head 89is opened and the appendix 80 is pulled between the stapling surfaces 93and the still loose control thread 91 by the help of a forceps 6.Thereafter the control thread 91 is tensioned along with the closure ofthe adjustable jaw 95 and the stapler 88 is closed at the origin of theappendix 80. After firing the stapler 88 the appendix 80 is removed.

The gall bladder 34 or the appendix 80 are removed from the abdominalcavity advantageously through the tube 28, and if the tube has a cap 47on the outer end 53, the cap 47 should be removed (e.g. FIG. 9/E). Ifthe tissue or organ is larger then the inner diameter of the tube 28,they are removed through the protective sheath 71 by pulling them intothe sheath 71 with an instrument 6 inside the tube 28 (FIGS. 24/B and26/B). The protective sheath 71 makes it possible to easily insert thepreviously removed laparo-endoscopic system back into the abdominalcavity.

In case of a non-divided endoscopic device 103 (FIG. 17/A) the steps ofthe procedure is similar to the previously described methods, exceptthat the endoscopic stapler 88 is inserted into the abdominal cavityoutside the laparo-endoscopic system.

If one part of the divided endoscopic device 66 (e.g. FIG. 15) isremoved, the endoscopic stapler 88 could be inserted through the emptiedspace. The size of the step-form opened 100 inner end of the divideddevice 66 could be adjusted to various operation fields bylongitudinally shifting back and forth the divided parts relative toeach other without creating additional wounds.

When performing SPLS interventions, the rigid instruments 6, trocarsleeves 7, tube 28 or endoscopic device 66, 103 are inserted through theumbilicus 60, and their inner ends are directed toward the operationfield (FIGS. 22 and 23). The outer end of the device system could befixed in the right position by an external fixateur 42. The furthersteps of the intervention are similar to the laparoscopic technique. Incase of a rigid device system there is no need to fix the inner end,however on request it is executable with a thread 23, a stick 51 or acontrol rod 61, as discussed earlier.

In case of a procedure performed inside a hollow organ 39 (e.g. theexcision of a pathological lesion 87 on the wall), the fixation of theinner end of the laparo-endoscopic device is achieved by a balloon 45that is slidable along the device (FIGS. 34/A and B). If the balloon 45is insufflated to an appropriate size, it becomes secured within thehollow organ, so the laparo-endoscopic system is able to lean on theballoon 45, and in addition the inner end is diverged form the stomachwall 39 to an appropriate distance. The advantageously multiple vacuumfixation could have similar effectiveness.

3. Closure

The closure means primarily the reliable closure of a wound opening 40on the wall of a hollow organ 39. As soon as the surgical interventionis completed, and the diseased organ or tissues are removed, and theoperation field is checked again, the protective sheath 71 or theendoscopic balloon tube 56 are removed through the mouth, while theinner ends of the connected trocar sleeves 7, or the inner end of thetube 28 or the endoscopic device 66, 103 remain within the abdominalcavity. Within the inner end opening there is advantageously a singlecamera 44 in a curved position, which makes the visual control in theadjacent region of the wound 40 possible. A wound closure system isattached with sliding connection 29 (advantageously through a connectinggroove 11 or rail 50) to the outer surface of the connected trocarsleeves 7, or the tube 28 or the endoscopic device 66, 103. Theimplanting tube 85 with the implanting sheath 82, locking elements 84,threads 23 and camera 44 inside is pushed against the stomach wall 39.The appropriate distance between the laparo-endoscopic system and theconnected implanting tube 85 allows to the locking elements 84 and thethreads 23 to reliably hold the lifted wound edges 40. Controlled by thecamera 44 of the implanting tube 85 the pointed shaped inner end of theimplanting sheath 82 is pushed through the wall of the hollow organ 39,and by pushing the implanting rod 83 a locking element 84 with thread 23is discharged (FIG. 18/C). The movement of the implanting sheath 82through the stomach wall 39 and the correct position of the lockingelements 84 are controlled by a curved (retroflexed) camera 44 insidethe abdominal cavity. This implanting maneuver should be repeated—byfollowing the full rotation of the laparo-endoscopic system within thewound 40—to implant the locking elements 84 into the wound edges 40around its whole circumference (FIG. 28). Then the laparo-endoscopicsystem is pulled back and removed from the patient, while the implantingtube 85 is dislodged from the laparo-endoscopic system by the help ofthe sliding connection 29 and remains in place. As a consequence, thelocking elements 84 within the wound edges 40, the threads 23 and thetube 85 containing the threads 23 remain inside the stomach 39. Bysimultaneously lifting the threads upward and by pushing the implantingtube 85 downward, the edges of the wound 40 are pulled up into the innerend of the implanting tube (FIG. 29/C). The outer end of the implantingtube 85 is introduced between the stapling surfaces 93 and the controlthread 91 of the stapler 88, and then the stapler 88 is pushed downalong the implanting tube 85 to the wound 40 trough the mouth (FIG. 30).Advantageously the stapler 88 has a camera 44.

In order to achieve better control over the process the endoscopicstapler 88 is bent at the articulation 4. After the control thread 91 isslightly tensioned the stomach 39 wound 40 is pulled between the openedstapling surfaces 93 and the control thread 91. After the adjustable jaw95 is closed while the control thread 91 is continuously tensioned, thesituation is checked again with the camera 44. Then the stapler 88 isfired and the wound 40 is closed and the stapled wound 94 is checkedwith the camera 44. This procedure could be performed with differenttype of staplers (FIGS. 31, 32 and 33).

The closure process after SPLS intervention means the traditionalclosure of the abdominal 41 or umbilical 61 incisions.

The closure of the wound 40 inside the hollow organ could be performedwith the wound closure system (discussed above) and the stapler 88, orwith the laparo-endoscopic system secured with a balloon 45 (FIG. 34/B).In the later case the wound 40 is closed from inside with sutures 96similarly to the laparoscopic suture technique.

The most important advantages of the solutions according to thisinvention shall be that they ensure to reliably accomplish all steps(access, surgical intervention, closure) of NOTES (Natural OrificeTransluminal Endoscopic Surgery), SPLS (Single Port LaparoscopicSurgery) and IE (Interventional Endoscopy) procedures through thenatural orifices, similarly to the reliable and well developedlaparoscopic techniques and maneuvers.

The invention claimed is:
 1. A surgical device for surgicalintervention, comprising an elongated tubular body having (i) an innerend guidable/steerable to an operation field, (ii) an outer end operableby a user and (hi) a middle part which connects said outer end to saidinner end, and force transmission units extending between the outer endand the inner end, said force transmission units, together with thetubular body adapted to transfer movement of the outer end to the innerend, and including (i) a first force transmission unit adapted totransfer rotational movement of the outer end to the inner end relativeto the middle part by the same rotational angle and in the samerotational direction, and (ii) a second force transmission unit adaptedto transfer axial movement of the outer end to the inner end relative tothe middle part by the same extent but in the opposite direction: andsurgical instrument has a channel inside, and the second forcetransmission unit comprises force transmission particles connected toeach other, and said particles fill in the whole length of the channel,and each of them have a hole, and through these holes of the particlestravels a motive wire.
 2. A surgical device according to claim 1characterized by comprising a trocar sleeve, and said surgicalinstrument being located within the trocar sleeve.
 3. A surgical deviceaccording to claim 1 characterized in that it has a tube comprising (i)a cylindrical body, (ii) an inner end and an outer end, and (iii) a gasconnection and a suction-irrigation connection, and said tube is adaptedto be housed inside at least one of a member of the group consisting ofa surgical instrument and a trocar sleeve.
 4. A surgical deviceaccording to claim 2 characterized in that on the outer surface of thetube's inner end the tube has a thread with a member of the groupconsisting of a needle and a stick which can be passed through theabdominal wall and can be fixed to an external fixateur.
 5. A surgicaldevice according to claim 2 characterized in that on the outer surfaceof the inner end the tube has a connecting point formed as a member ofthe group consisting of a groove and a rail designed to connect to acontrol rod for fixation to an abdominal wall.
 6. A surgical deviceaccording to claim 1 characterized in that the surgical device is formedas an endoscopic device comprising (i) a cylindrical body with an innerend and an outer end, (ii) more than one working channels, and (iii) agas connection and a suction-irrigation connection, and at least oneworking channel that is designed to receive at least one surgicalinstrument.
 7. A surgical device according to claim 6 characterized inthat on an outer surface of the inner end of the endoscopic device athread is provided with a member of the group consisting of a needle anda stick which can be passed through the abdominal wall and can be fixedto an external fixateur.
 8. A surgical device according to claim 6characterized in that on an outer surface of the inner end of theendoscopic device a connecting point is formed as a member of the groupconsisting of a groove and a rail designed to connect to a control rodfor fixation to an abdominal wall.
 9. A surgical device according toclaim 6 characterized in that the endoscopic device is designed to be atleast partially separable at least into two parts at a plane parallelwith the longitudinal axis, and said divided parts are connected bysliding connections, which are shiftable relative to each other.
 10. Asurgical device according to claim 6 characterized in that theendoscopic device is non-divided, and at the inner end there is a memberof the group comprising an oblique opening and a step-form designedopening.
 11. A surgical device for surgical intervention, comprising anelongated tubular body having (i) an inner end guidable/steerable to anoperation field, (ii) an outer end operable by a user and (hi) a middlepart which connects said outer end to said inner end, and forcetransmission units extending between the outer end and the inner end,said force transmission units, together with the tubular body adapted totransfer movement of the outer end to the inner end, and including (i) afirst force transmission unit adapted to transfer rotational movement ofthe outer end to the inner end relative to the middle part by the samerotational angle and in the same rotational direction, and (ii) a secondforce transmissions unit adapted to transfer axial movement of the outerend to the inner end relative to the middle part by the same extent butin the opposite direction; and the surgical device has a channel inside,and the second force transmission unit is a sealed hydraulic unitlocated inside the channel, which has an outer part inside the outer endand an inner part inside the inner end.
 12. A surgical device forsurgical intervention, comprising a surgical instrument having anelongate tubular instrument body having (i) an instrument inner endguidable/steerable to an operation field and having telescopicstructure, (ii) an instrument outer end operable by a user and havingtelescopic structure, (iii) an instrument middle part which connectssaid instrument outer end to said instrument inner end; the surgicaldevice further comprising a trocar sleeve having an elongate tubulartrocar body having a trocar inner end, a trocar outer end and a tubulartrocar middle part, the tubular middle part having an outer diameteradapted to be inserted into a human or animal body containing theoperation field, the trocar sleeve further having a third articulationprovided between the trocar outer end and the trocar middle part and afourth articulation provided between the trocar inner end and the trocarmiddle part; the surgical instrument being arranged in the trocar sleevesuch that the instrument middle part is located in the trocar middlepart; the trocar inner end surrounds at least partly the instrumentinner end, and the trocar outer end surrounds at least partly theinstrument outer end, the trocar sleeve comprising a first forcetransmission unit adapted to transfer rotational movement of the trocarouter end to the trocar inner end relative to the trocar middle part bythe same rotational angle and in the same rotational direction, and thesurgical instrument comprising a second force transmission unit adaptedto transfer axial movement of the instrument outer end to the instrumentinner end relative to the instrument middle part by the same extent butin the opposite direction, by elongating the telescopic instrument innerend when the telescopic instrument outer end is compressed, and bycontracting the telescopic instrument inner end when the telescopicinstrument outer end is elongated.
 13. A surgical device according toclaim 12 characterized in that the second force transmission unitcomprises force transmission particles located in a channel of thetubular body of the surgical instrument, the force transmissionparticles being connected to each other, and said particles fill in thewhole length of the channel.
 14. A surgical device according to claim 12characterized in that the second force transmission unit is a sealedhydraulic unit situated inside the channel of the surgical instrumentwhich has an outer part inside the outer end and an inner part insidethe inner end.
 15. A surgical device according to claim 12 characterizedin that the second force transmission unit is a slideable flexiblesheath inside the channel of the surgical instrument capable ofresisting compression along the longitudinal axis and torsion around thelongitudinal axis.
 16. A surgical device according to claim 12characterized in that the first force transmission unit is situated inthe trocar sleeve which contains the surgical instrument, and the secondforce transmission unit corresponds to the instrument which is capableof resisting compression along the longitudinal axis and torsion aroundthe longitudinal axis.
 17. A surgical device according to claim 12characterized in that it comprises more than one trocar sleeve eachhaving a trocar inner end, and the trocar inner ends of at least twotrocar sleeves terminate in planes that are spaced from each other. 18.Surgical device according to claim 17 characterized in that at least oneof said two trocar sleeves comprises at least one working channeltherein being connected with sliding connection to at least one othertrocar sleeve.